Louisiana Medicaid
Managed Care Organization (MCO)
Manual
Updated: 8/15/2024
(Replaces Version Published 7/23/2024)
MCO Manual | CONTENTS 2
Contents
PART 1: INTRODUCTION ................................................................................................................................... 12
Overview .............................................................................................................................................................. 12
Revisions .............................................................................................................................................................. 12
PART 2: ADMINISTRATION & CONTRACT MANAGEMENT ................................................................................ 14
Staffing ................................................................................................................................................................. 14
Business Owners .................................................................................................................................................. 21
LDH Managed Care Guidance .............................................................................................................................. 21
MCO Policy and Provider Manual Submission Guidance .................................................................................... 21
Reporting ............................................................................................................................................................. 22
Certification of Data and Reports .................................................................................................................... 22
Information Related to Business Transactions ................................................................................................ 22
Report of Transactions with Parties in Interest ............................................................................................... 23
Staffing ............................................................................................................................................................. 23
Health Needs Assessment ............................................................................................................................... 23
Encounter Data ................................................................................................................................................ 23
Financial Reporting .......................................................................................................................................... 24
Information on Persons Convicted of Crimes .................................................................................................. 24
Errors ............................................................................................................................................................... 24
Submission Timeframes .................................................................................................................................. 25
Recurring Reports ............................................................................................................................................ 25
Ad Hoc Reports ................................................................................................................................................ 25
Transparency Report ....................................................................................................................................... 26
Integration Assessment of Physical and Behavioral Health ................................................................................ 27
Legal Compliance ................................................................................................................................................. 28
AJ v. LDH .......................................................................................................................................................... 28
Chisholm v. LDH ............................................................................................................................................... 30
DOJ Agreement ................................................................................................................................................ 30
Monitoring of Denial Notices .......................................................................................................................... 31
Public Records Request Protocol ......................................................................................................................... 31
Receipt of Potential Public Records Request .................................................................................................. 31
Public Records Request (PRR) Points of Contact for LDH and MCOs .............................................................. 31
MCO Manual | CONTENTS 3
Transmission of the Public Records Request ................................................................................................... 32
Process for LDH to Evaluate Whether Records are Subject to the Louisiana Public Records law .................. 32
Notice to MCOs of Impending Release of Records MCO has Deemed Not Public and/or Meet an Exception to
the Public Records Law .................................................................................................................................... 32
PART 3: ELIGIBILITY & ENROLLMENT ................................................................................................................ 33
Certificate of Creditable Coverage ...................................................................................................................... 33
Newborn Enrollment ........................................................................................................................................... 33
Justice-Involved Enrollees ................................................................................................................................... 34
Eligibility Updates ................................................................................................................................................ 34
Medicaid Eligibility Determinations Based on SSI ........................................................................................... 34
Administrative Retroactive Corrections .............................................................................................................. 35
Retroactive Enrollment.................................................................................................................................... 35
Retroactive Disenrollment ............................................................................................................................... 35
Enrollee Retroactive Reimbursement ................................................................................................................. 36
Reimbursement Criteria .................................................................................................................................. 37
Bills Not Eligible for Reimbursement ............................................................................................................... 37
Reimbursements Involving Third Party Liability .............................................................................................. 37
Required Documentation ................................................................................................................................ 38
Processing Timeframes .................................................................................................................................... 38
Managed Care Linkage for Long Term Care Enrollees ........................................................................................ 38
Claims Responsibility ....................................................................................................................................... 39
Disenrollment Notification .............................................................................................................................. 40
PART 4: SERVICES .............................................................................................................................................. 41
MCO Covered Services ........................................................................................................................................ 41
Out-of-State Medical Care ............................................................................................................................... 44
Ambulatory Surgical Services .............................................................................................................................. 44
Ambulatory Surgical Centers (Non-Hospital) .................................................................................................. 45
Outpatient Hospital Ambulatory Surgery ........................................................................................................ 46
Behavioral Health Services .................................................................................................................................. 47
Emergency Certificates for Inpatient or Residential Behavioral Health Services ............................................ 47
Pre-Admission Screening and Resident Review .............................................................................................. 48
Specialized Behavioral Health Evidence-Based Practice Programs ................................................................. 49
Emergency Services ............................................................................................................................................. 50
MCO Manual | CONTENTS 4
Emergency Medical Services ........................................................................................................................... 50
Post-Stabilization Services ............................................................................................................................... 50
Emergency Ancillary Services Provided at the Hospital .................................................................................. 51
Hospital Services .................................................................................................................................................. 51
General Policies ............................................................................................................................................... 52
Inpatient Hospital Services .............................................................................................................................. 54
Outpatient Hospital Services ........................................................................................................................... 64
Laboratory Services ............................................................................................................................................. 69
CLIA Certification ............................................................................................................................................. 70
In-Office Laboratory Services .......................................................................................................................... 70
Hospital Laboratory Services ........................................................................................................................... 70
Independent Laboratories ............................................................................................................................... 70
Specimen Collection ........................................................................................................................................ 71
Urine Drug Testing ........................................................................................................................................... 71
Medical Transportation ....................................................................................................................................... 71
Non-Emergency Medical Transportation ........................................................................................................ 72
Ambulance ....................................................................................................................................................... 87
Record Retention ............................................................................................................................................. 97
Personal Care Services ......................................................................................................................................... 97
Electronic Visit Verification for EPSDT PCS and Behavioral Health PCS .......................................................... 97
Pharmacy ............................................................................................................................................................. 97
Covered Drug List ............................................................................................................................................ 98
Preferred Drug List .......................................................................................................................................... 99
Behavioral Health Specific Pharmacy Policies and Procedures ..................................................................... 100
Brand Name and Generic Drugs .................................................................................................................... 101
Drug Utilization Review Program .................................................................................................................. 101
Lock-In Program ............................................................................................................................................. 106
Medication Therapy Management ................................................................................................................ 107
Mosquito Repellent Coverage ....................................................................................................................... 110
Opioid Prescription Policy ............................................................................................................................. 111
Clotting Factor ............................................................................................................................................... 112
Pharmacy Copayment ................................................................................................................................... 112
Prior Authorization ........................................................................................................................................ 112
MCO Manual | CONTENTS 5
340B Policy for Claim Level Indicators ........................................................................................................... 114
Emergencies .................................................................................................................................................. 116
Portable X-Ray Services ..................................................................................................................................... 116
Covered Services
.......................................................................................................................................... 116
Enrollee Qualifications
................................................................................................................................. 117
Provider Requirements
................................................................................................................................ 117
Professional Services ......................................................................................................................................... 118
Abortion ......................................................................................................................................................... 118
Advanced Practice Registered Nurses: Clinical Nurse Specialists, Certified Nurse Practitioners, and Certified
Nurse Midwives ............................................................................................................................................. 119
After Hours Care on Evenings, Weekends, and Holidays .............................................................................. 120
Allergy Testing and Allergen Immunotherapy ............................................................................................... 121
Anesthesia ..................................................................................................................................................... 121
Assistant Surgeon/Assistant at Surgery ......................................................................................................... 126
Bariatric Surgery ............................................................................................................................................ 126
Breast Surgery ............................................................................................................................................... 128
Cardiovascular Services ................................................................................................................................. 129
Chiropractic Services ..................................................................................................................................... 133
Cochlear Implant ........................................................................................................................................... 133
Community Health Workers .......................................................................................................................... 134
Concurrent Care – Inpatient .......................................................................................................................... 136
Diabetes Self-Management Training ............................................................................................................. 136
Early and Periodic Screening, Diagnostic, and Treatment Preventive Services Program ............................. 140
Eye Care and Vision Services ......................................................................................................................... 147
Family Planning Services................................................................................................................................ 147
Genetic Counseling and Testing .................................................................................................................... 148
Gynecology .................................................................................................................................................... 151
Home Health Services .................................................................................................................................... 154
Hyperbaric Oxygen Therapy .......................................................................................................................... 155
Immunizations ............................................................................................................................................... 155
“Incident to” Services .................................................................................................................................... 157
Institutional Long-Term Care Facilities/Nursing Homes ................................................................................ 157
Intrathecal Baclofen Therapy ........................................................................................................................ 158
MCO Manual | CONTENTS 6
LSU Enhanced Professional Service Fees ....................................................................................................... 159
Modifiers ....................................................................................................................................................... 160
Multiple Surgical Reduction Reimbursement ................................................................................................ 163
Newborn Care and Discharge ........................................................................................................................ 163
Obstetrics ...................................................................................................................................................... 164
Organ Transplants ......................................................................................................................................... 169
Physician Administered Medication .............................................................................................................. 169
Physician Assistants ....................................................................................................................................... 169
Preventive Services for Adults ....................................................................................................................... 170
Radiology Services ......................................................................................................................................... 170
Qualifying Clinical Trial .................................................................................................................................. 171
Coverage Limitations ..................................................................................................................................... 172
Sinus Procedures ........................................................................................................................................... 172
Skin Substitutes for Chronic Diabetic Lower Extremity Ulcers ...................................................................... 173
Sterilizations .................................................................................................................................................. 174
Substitute Physician Billing ............................................................................................................................ 176
Telemedicine/Telehealth ............................................................................................................................... 177
Therapy Services ............................................................................................................................................ 178
Tobacco Cessation Counseling Services ........................................................................................................ 178
Vagus Nerve Stimulators ............................................................................................................................... 179
In Lieu of Services .............................................................................................................................................. 180
Physical Health Services ................................................................................................................................ 180
Behavioral Health Services ............................................................................................................................ 192
Value-Added Benefits ........................................................................................................................................ 194
Prohibited and Non-Covered Services ............................................................................................................... 195
Provider Preventable Conditions ................................................................................................................... 196
PART 5: CARE MANAGEMENT ......................................................................................................................... 198
Independent Evaluations for PASRR Level II ..................................................................................................... 198
PASRR Tracking .................................................................................................................................................. 199
Services to Comply with the DOJ Agreement .................................................................................................... 199
Women, Infant, and Children (WIC) Program Referral ..................................................................................... 199
PART 6: POPULATION HEALTH AND SOCIAL DETERMINANTS OF HEALTH ..................................................... 200
Staffing Roles and Responsibilities .................................................................................................................... 200
MCO Manual | CONTENTS 7
PART 7: PROVIDER CLAIMS & REIMBURSEMENT ........................................................................................... 202
Exceptions to Claims Timely Filing Guidelines ................................................................................................... 202
Adjustments and Voids ...................................................................................................................................... 202
Interest Payments ............................................................................................................................................. 203
Payment Recoupments ..................................................................................................................................... 203
FQHC/RHC Contracting and Reimbursement .................................................................................................... 203
PART 8: ENCOUNTERS ..................................................................................................................................... 204
Claims Summary Report .................................................................................................................................... 204
Encounters Greater Than $1 Million ................................................................................................................. 204
Pharmacy Encounters ........................................................................................................................................ 204
Disputed Pharmacy Encounter Submissions ................................................................................................. 204
Skilled Nursing Facilities Encounter Claims ........................................................................................................ 205
PART 9: PROVIDER NETWORK ......................................................................................................................... 206
Availability and Accessibility Requirements ...................................................................................................... 206
Provider Enrollment .......................................................................................................................................... 210
Other Enrollment and Disenrollment Requirements .................................................................................... 210
Credentialing and Re-credentialing of Providers and Clinical Staff ................................................................... 210
Specialized Behavioral Health Providers ....................................................................................................... 210
Permanent Supportive Housing Providers .................................................................................................... 213
Primary Care ...................................................................................................................................................... 214
PCP Automatic Assignment ........................................................................................................................... 214
PCP Designation for Enrollees ....................................................................................................................... 215
Enrollee Reassignment Policy ........................................................................................................................ 215
Referral System for Specialty Health Care ..................................................................................................... 217
Access to Medication Assisted Treatment ........................................................................................................ 217
Specialized Behavioral Health Providers ........................................................................................................... 218
Integration of Primary Care and Behavioral Health Services ............................................................................ 219
Services for Co-Occurring Behavioral Health and Developmental Disabilities ................................................. 219
Network Development and Management Plan ................................................................................................. 220
Material Change to Provider Network .............................................................................................................. 222
Pharmacy Network, Access Standards, and Reimbursement ........................................................................... 223
Pharmacy Claims Dispute Management ....................................................................................................... 223
Specialty Drugs and Specialty Pharmacies .................................................................................................... 223
MCO Manual | CONTENTS 8
Internal Claims Dispute Process .................................................................................................................... 225
PART 10: PROVIDER SERVICES .......................................................................................................................... 226
Provider Directory ............................................................................................................................................. 226
Provider Website ............................................................................................................................................... 226
Provider Handbook ............................................................................................................................................ 226
Specialized Behavioral Health Provider Training Requirements ....................................................................... 227
Provider Issue Resolution .................................................................................................................................. 228
Claim Reconsideration, Appeal, and Arbitration ........................................................................................... 228
Independent Review...................................................................................................................................... 229
Provider Issue Escalation and Resolution ...................................................................................................... 229
Enrollee Reassignment Policy ............................................................................................................................ 230
PART 11: ENROLLEE SERVICES .......................................................................................................................... 231
Authorized Representatives or Legal Representatives ..................................................................................... 231
Enrollee Rights and Responsibilities .................................................................................................................. 232
Grievances, Appeals, and State Fair Hearings ................................................................................................... 233
Continuation of Benefits ............................................................................................................................... 233
Medical Records ................................................................................................................................................ 233
Returned Mail Procedures ................................................................................................................................. 234
PART 12: MARKETING AND EDUCATION .......................................................................................................... 235
Events and Activities Approval Process ............................................................................................................. 235
Focus Groups ..................................................................................................................................................... 235
Reporting ........................................................................................................................................................... 236
Marketing and Member Education Plan ....................................................................................................... 236
Marketing and Member Education Report ................................................................................................... 237
Alleged Marketing Violations ........................................................................................................................ 237
MCO Brand and Logo ......................................................................................................................................... 237
Steering .............................................................................................................................................................. 237
PART 13: QUALITY ............................................................................................................................................. 239
Performance Improvement Projects ................................................................................................................. 239
Performance Improvement Projects Reporting Requirements .................................................................... 240
Enrollee Advisory Council .................................................................................................................................. 240
Adverse Incident and Quality of Care Concerns Management and Reporting ................................................. 241
Outcome Assessment for Behavioral Health Services ....................................................................................... 242
MCO Manual | CONTENTS 9
Quality Monitoring Reviews for Behavioral Health Providers ........................................................................... 242
PART 14: VALUE-BASED PAYMENT ................................................................................................................... 244
VBP Strategic Plan ............................................................................................................................................. 244
Minimum VBP Threshold and Qualifying VBP Arrangements ........................................................................... 244
Physician Incentive Plan .................................................................................................................................... 244
PART 15: PROGRAM INTEGRITY ........................................................................................................................ 245
Investigations .................................................................................................................................................... 245
Referrals/Notices ............................................................................................................................................... 245
Reporting ........................................................................................................................................................... 245
Tips .................................................................................................................................................................... 246
FWA Compliance Program ................................................................................................................................. 246
Program Integrity Meetings .............................................................................................................................. 246
Exclusions & Prohibited Affiliations ................................................................................................................... 246
Sampling of Paid Claims ..................................................................................................................................... 247
Overpayments ................................................................................................................................................... 247
Prepayment Review ........................................................................................................................................... 247
Audit Coordination ............................................................................................................................................ 248
Surveillance and Utilization Review Audit Coordination ............................................................................... 248
Unified Program Integrity Contractor Audit Coordination ............................................................................ 249
PART 16: PAYMENT & FINANCIAL PROVISIONS ................................................................................................ 250
Capitated Payments .......................................................................................................................................... 250
Kick Payments .................................................................................................................................................... 250
MCO Payment Schedule .................................................................................................................................... 250
Financial Incentives for MCO Performance ....................................................................................................... 250
Medical Loss Ratio ............................................................................................................................................. 250
Risk Sharing........................................................................................................................................................ 250
Determination of MCO Rates ............................................................................................................................ 251
Risk Adjustment ................................................................................................................................................. 251
Return of Funds ................................................................................................................................................. 251
Cost Sharing ....................................................................................................................................................... 251
PART 17: THIRD PARTY LIABILITY ...................................................................................................................... 253
Cost Avoidance .................................................................................................................................................. 254
Pay and Chase vs. Wait and See ........................................................................................................................ 254
MCO Manual | CONTENTS 10
Managing Third Party Liability File Exchanges and Enrollee Updates ............................................................... 255
Post-Payment Recoveries from Providers and Liable Third Parties .................................................................. 256
Exclusions to Post-Payment Recoveries from Providers ............................................................................... 257
Encounters for Post-Payment Recoveries ..................................................................................................... 257
TPL Scope Of Coverage ...................................................................................................................................... 257
Provider Portal Response for TPL Scope of Coverage ................................................................................... 257
Utilization of Scope of Coverage 27 (Major Medical, No Maternity Benefits) and 33 (HMO, No Maternity
Benefits)......................................................................................................................................................... 257
LaHIPP ................................................................................................................................................................ 258
Calculation of Payment for LaHIPP Secondary Claims .................................................................................. 258
TPL Payment & TPL Payment Calculation .......................................................................................................... 259
Scenario 1 Professional Claim ....................................................................................................................... 259
Scenario 2 Outpatient Claim .......................................................................................................................... 259
Scenario 3 Inpatient Claim ............................................................................................................................. 259
Scenario 4: FQHC/RHC/American Indian Clinic ............................................................................................. 259
Scenario 5 Outpatient Pharmacy Claim ......................................................................................................... 260
Scenario 6: LaHIPP Enrollee Claim ................................................................................................................. 260
Liens (Trauma Recovery) ................................................................................................................................... 260
Approval Guidelines for Trauma Recovery Lien Settlements Equal to or Greater Than $25,000 ................. 260
Guidelines for Prior Notice of Trauma Recovery Subrogation Vendor and Process Changes ...................... 261
Coordination of Benefits ................................................................................................................................... 262
Other Coverage Information and Third Party Liability Data Exchange ......................................................... 262
Reporting and Tracking.................................................................................................................................. 262
PART 18: SYSTEMS AND TECHNICAL REQUIREMENTS ...................................................................................... 263
General Requirements....................................................................................................................................... 263
HIPAA Standards and Code Sets ........................................................................................................................ 263
Connectivity ....................................................................................................................................................... 263
Hardware and Software .................................................................................................................................... 263
Desktop Workstation Hardware .................................................................................................................... 263
Desktop Workstation Software ..................................................................................................................... 263
Network and Back-up Capabilities .................................................................................................................... 264
Provider Enrollment .......................................................................................................................................... 264
RESOURCES 265
MCO Manual | CONTENTS 11
Manuals and Guides .......................................................................................................................................... 265
Fee Schedules .................................................................................................................................................... 265
Forms and Templates ........................................................................................................................................ 265
MCO Manual | INTRODUCTION 12
PART 1: INTRODUCTION
OVERVIEW
The Managed Care Organization (MCO) Manual is a compilation of policies, instructions, and guidelines
established by the Louisiana Department of Health (LDH) for the administration of the Louisiana Medicaid
managed care program. The purpose of this Manual is to provide clarifying information and operational guidelines
to support the MCO in complying with the terms of its contract with LDH (hereinafter, the “Contract”). This Manual
is intended to accompany the Contract rather than be a standalone and exhaustive compilation of contractual
requirements.
This Manual applies to MCOs contracted by LDH to provide coverage for services to Louisiana Medicaid managed
care program enrollees, effective January 1, 2023. This Manual also applies to major subcontractors with
delegated responsibilities for the provision of all, or part, of any program area or function that relates to the
delivery or reimbursement of covered services, including, but not limited to, behavioral health, claims processing,
care management, utilization management, transportation, or pharmacy benefits, including specialty pharmacy
providers.
The MCO is solely responsible for complying with the requirements set forth within this Manual and in the
Contract whether or not subcontractors are used. In addition, the MCO is responsible for ensuring compliance by
its subcontractors. In the event of a perceived discrepancy between the Contract and this Manual, the MCO shall
seek clarification from LDH prior to taking action.
REVISIONS
This Manual may be revised at the discretion of LDH due to a variety of reasons, including, but not limited to,
changes to any provisions of state and federal laws, regulations, rules, the Louisiana Medicaid State Plan, and
waivers applicable to managed care, Contract amendments, internal operational changes, and requests for
written guidance in a particular area.
In accordance with Louisiana Revised Statutes La. R.S. 46:460.54, prior to adopting, approving, amending, or
implementing certain policies or procedures
1
contained in the Manual, LDH will publish the proposed policy or
procedure on the LDH website for a period of no less than 45 calendar days for the purpose of soliciting public
comments. The public comment period will not apply if LDH finds that an imminent peril
2
to the public health,
1
Per La. R.S. 46:460.51, “Policy or procedure” shall mean a requirement governing the administration of managed care
organizations specific to billing guidelines, medical management and utilization review guidelines, case management
guidelines, claims processing guidelines and edits, grievance and appeals procedures and process, other guidelines or
manuals containing pertinent information related to operations and pre-processing claims, and core benefits and services.
2
Imminent peril is defined as sudden, urgent and critical situations that call for aid to the public health, safety, or welfare
that require immediate approval of a proposed policy or procedure or manual revision without otherwise publishing the
proposed policy or procedure or revision as required by standard timelines required under La. R.S. 46:460.53 and 46:460.54.
MCO Manual | INTRODUCTION 13
safety, or welfare requires immediate adoption of the proposed policy or procedure. The public comment period
also will not apply for non-material
3
revisions.
Once approved by LDH, the revised Manual will be posted on the LDH website. The MCO may subscribe via e-mail
to heal[email protected]v
to be notified of updates. The MCO is responsible for notifying subcontractors and executing
necessary subcontract amendments when revisions are made to the Manual.
3
Non-material revisions are defined as typographical, grammatical, formatting, or stylistic edits only, including, but not
limited to, word changes that do not impact or affect overall content. Non-material changes have no programmatic or
monetary impact on providers.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 14
PART 2: ADMINISTRATION & CONTRACT
MANAGEMENT
The MCO’s business administration, organization, and oversight of all contracted responsibilities is critical to
achieving LDH’s goal of building a Medicaid managed care delivery system that improves the health of populations,
enhances the experience of care for individuals, and effectively manages Medicaid per capita care costs.
STAFFING
In addition to the key personnel requirements of the Contract, the MCO shall have these additional staff.
Program Integrity Officer shall be qualified by training and experience in health care or risk management,
to oversee monitoring and enforcement of the fraud, waste, and abuse compliance program to prevent
and detect potential fraud, waste, and abuse activities pursuant to state and federal rules and regulations,
and carry out the provisions of the compliance plan, including fraud, waste, and abuse policies and
procedures, investigating unusual incidents and implementing any corrective action plans. As a
management official, this position shall have the authority to assess records and independently refer
suspected enrollee fraud, provider fraud, and enrollee abuse cases to LDH and other duly authorized
enforcement agencies. The Program Integrity Officer must report directly to the CEO and be located in
Louisiana.
Grievance System Manager shall manage and adjudicate enrollee and provider disputes arising under the
Grievance System including enrollee grievances, appeals and requests for hearing and provider complaints
and disputes. The Grievance System Manager shall be located in Louisiana.
Business Continuity Planning and Emergency Coordinator shall manage and oversee the MCO’s Continuity
of Operations Plan during disasters and ensure continuity of covered services for enrollees who may need
to be evacuated to other areas of the state or out-of-state.
Information Technology Director shall be trained and experienced in information systems, data processing
and data reporting and shall be responsible for oversight of all MCO information systems functions
including, but not limited to, establishing and maintaining connectivity with LDH.
Provider Claims Educator must be a full-time (40 hours per week) employee located in Louisiana. This
position is fully integrated with the MCO’s complaint, claims processing, and provider relations systems
and facilitates the exchange of information between these systems and providers, with a minimum of five
years management and supervisory experience in the healthcare field. The primary functions of the
Provider Claims Educator include:
o Educating in-network and out-of-network providers regarding appropriate claims submission
requirements, coding updates, electronic claims transactions and electronic fund transfer, and
available MCO resources, such as provider manuals, websites, fee schedules, etc.;
o Interfacing with the MCO’s provider call center to compile, analyze, and disseminate information
from provider calls;
o Identifying trends and guiding the development and implementation of strategies to improve
provider satisfaction; and
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 15
o Frequently communicating (i.e., telephonic and on-site) with providers to ensure the effective
exchange of information and to gain feedback regarding the extent to which providers are
informed about appropriate claims submission practices.
Encounter Data Quality Coordinator shall organize and coordinate services and communication between
MCO administration and LDH for the purpose of identifying, resolving, and monitoring encounter and data
validation/management issues. The Coordinator shall serve as the MCO’s encounter expert to answer
questions, provide recommendations, and participate in problem solving and decision-making related to
encounter data, submissions, and processing. The Coordinator analyzes activities related to the processing
of encounter data and data validation studies to enhance accuracy and throughout. This position shall be
located in Louisiana.
Quality Management (QM) Coordinator shall be a full-time, Louisiana-licensed registered nurse, advanced
practice registered nurse, physician, or physician's assistant, or a Certified Professional in Health Care
Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care
Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review
Providers. Six Sigma or other training in quality management is preferred. The QM Coordinator must be
located in Louisiana and have experience in quality management and quality improvement as described
in 42 C.F.R. §§ 438.206 – 438.242. The primary functions, including those targeting specialized behavioral
health services, of the QM Coordinator position include:
o Ensuring individual and systemic quality of care;
o Integrating quality throughout the organization;
o Implementing process improvement;
o Resolving, tracking and trending quality of care grievances; and,
o Ensuring a credentialed provider network.
Performance/Quality Improvement Coordinator shall be a certified professional in healthcare quality
(CPHQ) or certified in health care quality and management (CHCQM) or comparable education and
experience in data and outcomes measurement as described in 42 C.F.R. §§ 438.206–438.242. The
primary functions of the Performance/Quality Improvement Coordinator, including those targeting
specialized behavioral health services, include:
o Focusing organizational efforts on improving clinical quality performance measures;
o Developing and implementing performance improvement projects;
o Utilizing data to develop intervention strategies to improve outcome; and,
o Reporting quality improvement/performance outcomes.
Maternal Child Health/EPSDT Coordinator shall be a Louisiana licensed registered nurse, advanced
practice registered nurse, physician, or physician’s assistant; or has a Master’s degree in health services,
public health, or healthcare administration or other related field and/or a CPHQ or CHCQM. This position
shall be located in Louisiana. Staffing under this position should be sufficient to meet quality and
performance measure goals. The primary functions of the MCH/EPSDT Coordinator include:
o Ensuring delivery of EPSDT services;
o Ensuring delivery of maternal and postpartum care;
o Promoting family planning services;
o Promoting preventive health strategies;
o Identifying and coordinating assistance for identified enrollee needs specific to maternal/child
health and EPSDT;
o Interfacing with community partners; and
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 16
o Interfacing with the Office of Public Health-Bureau of Family Health and other child-serving state
health agencies to coordinate resource and information sharing around provision of EPSDT
services.
Medical Management Coordinator shall be a Louisiana-licensed registered nurse, advanced practice
registered nurse, physician or physician's assistant if required to make medical necessity determinations;
or have a Master’s degree in health services, healthcare administration, or business administration, if not
required to make medical necessity determinations, to manage all required Medicaid management
requirements under LDH policies, rules and the contract. This position shall be located in Louisiana. The
primary functions of the Medical Management Coordinator include:
o Ensuring adoption and consistent application of appropriate inpatient and outpatient medical
necessity criteria;
o Ensuring that appropriate concurrent review and discharge planning of inpatient stays is
conducted;
o Developing, implementing and monitoring the provision of care coordination, disease
management and case management functions;
o Monitoring, analyzing and implementing appropriate interventions based on utilization data,
including identifying and correcting over- or under- utilization of services; and,
o Monitoring prior authorization functions and assuring that decisions are made in a consistent
manner based on clinical criteria and meet timeliness standards.
Case Management Administrator/Manager shall oversee the case management functions and shall have
the qualifications of a case manager with a minimum of five years of management/supervisory experience
in the healthcare field.
Provider Services Manager shall coordinate communications between the MCO and its network providers.
This position shall be located in Louisiana.
Enrollee Services Manager shall coordinate communications between the MCO and its enrollees. This
position shall be located in Louisiana. There shall be sufficient Enrollee Services staff to enable enrollees
to receive prompt resolution of their problems or inquiries and appropriate education about participation
in the MCO program.
Behavioral Health Coordinator shall meet the requirements for a licensed mental health professional
(LMHP) and have at least seven years’ experience in managing behavioral healthcare operations. The
Behavioral Health Coordinator shall have responsibility for clinical program development and oversight of
staff and services related to the delivery of covered mental health and addiction services to
children/youth, adults with serious mental illness and/or with substance use disorders in compliance with
federal and state laws and the requirements set forth in the Contract, including the 24-hour behavioral
health crisis line, and all documents incorporated by reference. The Behavioral Health Coordinator will
share responsibility to manage the specialized behavioral health services delivery system, including crisis
response services implemented via the Louisiana Crisis Response System, with the Behavioral Health
Medical Director. The Behavioral Health Coordinator shall regularly review integration performance,
network adequacy, performance improvement projects, and surveys related to integration and shall work
closely with the Performance/Quality Improvement Coordinator, Behavioral Health Network Director,
Quality Management Coordinator, and Behavioral Health Quality Management Coordinator. Additionally,
the Behavioral Health Coordinator shall participate in statewide coalitions regarding the implementation
of crisis response services through the Louisiana Crisis Response System and ensure MCO participation in
regional coalitions developed through this initiative. This position shall be based in Louisiana.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 17
Behavioral Health Children’s System Administrator must meet the requirements for a LMHP and have at
least seven years’ experience and expertise in the specialized behavioral health needs of children with
severe behavioral health challenges and their families. Prior experience working with other child serving
systems is preferred. The ideal candidate will have at least three years’ experience with delivering or
managing Evidenced Based Practices (EBPs) and best practices for children and youth, including
experience within system of care and wraparound environments. The Children’s BH System Administrator
shall work closely with LDH and the Coordinated System of Care (CSoC) Governance Board, as needed.
This position shall be based in Louisiana.
Addictionologist or Addiction Services Manager (ASM) shall meet the requirements of a licensed addiction
counselor (LAC) or LMHP with at least seven years of clinical experience with addiction treatment of adults
and children experiencing substance use problems and disorders. The ASM shall be responsible for
oversight and compliance with the addiction principles of care and application of American Society of
Addiction Medicine (ASAM) placement criteria for all addiction program development. The ASM will work
closely with the COO, the Behavioral Health Coordinator, the Quality Management Coordinator, and the
Behavioral Health Medical Director in assuring quality, appropriate utilization management, and adequacy
of the addiction provider network. This position shall be located in Louisiana.
Behavioral Health Case Management Supervisor for specialized behavioral health services shall be a
Louisiana-licensed psychiatrist or a Louisiana-licensed Mental Health Practitioner (i.e., Medical
Psychologist, Licensed Psychologist, Licensed Clinical Social Worker, Licensed Professional Counselor,
Licensed Marital and Family Therapist, Licensed Addictions Counselor, or Advanced Practice Registered
Nurse, who is a nurse practitioner specialist in Adult Psychiatric and Mental Health, family Psychiatric and
Mental Health, or a Certified Nurse Specialist in Psychosocial, Gerontological Psychiatric Mental Health,
Adult Psychiatric and Mental Health, and Child-Adolescent Mental Health). A Case Management
Supervisor for medical services is a Louisiana-licensed registered nurse. The Case Management Supervisor
shall be responsible for all staff and activities related to the case management program, and shall be
responsible for ensuring the functioning of case management activities across the continuum of care. This
position shall be located in Louisiana.
Claims Administrator shall be responsible for the administration of a comprehensive claims processing
system capable of paying claims in accordance with state and federal requirements. The primary functions
of the Claims Administrator are:
o Developing and implementing claims processing systems capable of paying claims in accordance
with state and federal requirements and the terms of the Contract;
o Developing processes for cost avoidance;
o Ensuring minimization of claims recoupments;
o Meeting claims processing timelines; and
o Meeting LDH encounter reporting requirements.
Housing Specialist shall be responsible for ensuring that enrollees transitioning from facility to community
are connected to appropriate housing resources, including, but not limited to, referral of potential
enrollees to the MCO’s Permanent Supportive Housing liaison for application to the Louisiana Permanent
Supportive Housing program. The Housing Specialist shall also serve on the multi-disciplinary care team.
Prior Authorization Staff to authorize health care 24 hours per day, 7 days per week. This staff shall include
a Louisiana licensed registered nurse, advanced practice registered nurse, physician or physician's
assistant. The staff will work under the direction of a Louisiana-licensed registered nurse, advanced
practice registered nurse, physician or physician's assistant.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 18
o The MCO shall have a sufficient number of LMHPs, including licensed addiction counselors (LACs),
as well as a board-certified psychiatrist and a board-certified addictionologist. If an
addictionologist cannot be retained full-time due to limited availability, the MCO shall contract
with a qualified consultant. With the exception of the addictionologist who shall be available at
least 10 hours per week, the other LMHPs shall be available 24 hours per day, 7 days per week.
The MCO shall provide UM staff, both experienced and specifically assigned to children, youth,
adults, and older adults, and permanent support housing (PSH).
Concurrent Review Staff to conduct inpatient concurrent review. This staff shall include of a Louisiana
licensed registered nurse, advanced practice registered nurse, physician, or physician's assistant. The staff
will work under the direction of a Louisiana licensed registered nurse, advanced practice registered nurse,
physician or physician's assistant.
o The MCO shall have a sufficient number of LMHPs, including licensed addiction counselors (LACs),
as well as a board-certified psychiatrist and a board-certified addictionologist. If an
addictionologist cannot be retained full-time due to limited availability, the MCO shall contract
with a qualified consultant. With the exception of the addictionologist who shall be available at
least 10 hours per week, the other LMHPs shall be available 24 hours per day, 7 days per week.
The MCO shall provide UM staff, both experienced and specifically assigned to children, youth,
adults, and older adults, and permanent support housing (PSH).
Clerical and Support Staff to ensure proper functioning of the MCO's operation.
Physical Health Provider Services Staff to enable providers to receive prompt responses and assistance
and handle physical health provider complaints and appeals. Provider Services staff shall be dedicated to
the Louisiana Medicaid product, and there shall be sufficient Provider Services staff to enable providers
to receive prompt resolution of their problems and inquiries and appropriate education about
participation in the MCO and to maintain a sufficient provider network.
Behavioral Health Provider Services Staff to enable providers to receive prompt responses and assistance
and handle behavioral health provider complaints and appeals. There shall be sufficient Provider Services
staff to enable providers to receive prompt resolution of their problems and inquiries and appropriate
education about participation in the MCO and to maintain a sufficient provider network.
Peer Support Specialist Staff to focus on peer to peer activities providing advocacy and the creation of a
system which will enable an individual’s resiliency and recovery.
Enrollee Services Staff to enable enrollees to receive prompt responses and assistance. There shall be
sufficient Enrollee Services staff, 100% dedicated exclusively to LA Medicaid, to enable enrollees and
potential enrollees to receive prompt resolution of their problems or inquiries.
Claims Processing Staff to ensure the timely and accurate processing of original claims, resubmissions and
overall adjudication of claims.
Encounter Processing Staff to ensure the timely and accurate processing and submission to LDH of
encounter data and reports.
Care Management Staff to assess, plan, facilitate and advocate options and services to meet the enrollees’
health needs through communication and available resources to promote quality cost-effective
outcomes. The MCO shall provide and maintain in Louisiana, appropriate levels of care management staff
necessary to ensure adequate local geographic coverage for in-field face-to-face contact with physicians
and enrollees as appropriate and may include additional out of state staff providing phone consultation
and support.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 19
o An adequate number of care management staff necessary to support enrollees in need of
specialized behavioral health services shall be certified in treatment planning through the
completion of specialized training in the Treatment Planning Philosophy.
o For the population receiving specialized behavioral health services, the MCO shall have integrated
care management centers/care management staff that physically co-locate with care
management staff. The MCO shall employ case managers to coordinate follow-up to specialty
behavioral health providers and follow-up with enrollees to improve overall health care.
o The MCO shall have an adequate number of care management staff necessary to support
enrollees who meet target population criteria for the DOJ agreement. This care management
staff for the DOJ Agreement Target Population shall include coverage for in field face-to-face
contact with physicians/providers, enrollees, family members, LDH Transition Coordinators, and
other community resources/supports as appropriate.
Fraud, Waste, and Abuse Investigators are responsible for all fraud, waste, and abuse detection activities,
including the fraud and abuse compliance plan, MCO employee training and monitoring, sampling
investigation of paid claim discrepancies, and day-to-day provider investigation related inquiries. These
positions shall be located in Louisiana and staffed at a ratio of one per 50,000 enrollees.
Licensed Mental Health Professionals (LMHP)
o LMHP staff must be trained to determine the medical necessity criteria as established by the State.
LMHPs shall be certified in administering the Level of Care Utilization System (LOCUS). LMHPs
must be available to accept and respond to calls via warm transfer from the 24-hour behavioral
health crisis line.
o To perform PASRR Level II evaluations upon referrals from OBH to assess the appropriateness of
nursing facility placement and the need for, and facilitation of, behavioral health services. PASRR
Level II evaluations must be performed by an LMHP independent of OBH and not delegated to a
nursing facility or an entity that has a direct or indirect affiliation or relationship with a nursing
facility as per 42 C.F.R. § 483.106. Whether through subcontract or direct employment, the MCO
shall maintain appropriate levels of LMHP staff to ensure adequate local geographic coverage for
in field face-to-face contact with enrollees in need of such evaluations. These staff must be
administratively separate from staff performing utilization review but may be the same staff as
listed under the “Licensed Mental Health Professionals (LMHP)” additional staff requirement.
Behavioral Health Liaisons and Coordination with Partner Agencies to provide liaison activities for the
following entities. The liaison shall be available for response to inquiries within one business day of
inquiry. Any change in liaison personnel shall be sent to respective entity within 48 hours of notice to the
MCO.
o A liaison dedicated solely to LDOE, DCFS and OJJ. This liaison shall also be responsible for outreach,
education and community involvement for the court systems, education systems and law
enforcement. This staff position must be located in Louisiana. The designated liaison must attend
all CSoC Governance Board meetings. The liaison shall have experience in child welfare and
delinquency. The liaison shall also outreach to local school systems to educate on the services
available. The liaison shall be knowledgeable and provide education on the entire behavioral
health service array, including CSoC, crisis services and process for obtaining services and out of
home placements and process for placement.
o A single point of contact dedicated to liaising with the judicial system. Functions include serving
as a point of contact for judges, court personnel and appearing in court when requested by the
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 20
court system or LDH. This contact shall also serve as a point of contact for LDH legal and staff
working with LDH custody cases. This person shall have familiarity with drug court, juvenile court,
family court and criminal court processes and issues. This person shall provide continuous
outreach and education to the judicial system on access to services. This staff person may also
serve the function listed above as the DCFS/OJJ point of contact; however, if LDH determines the
caseload to be too voluminous, LDH may request an additional staff person be hired.
o Local Governing Entity (LGE) liaison who shall serve as a point of contact for inquiries, barriers and
resolution for LGEs. The liaison shall have experience with the LGE structure, services provided,
members served and responsibilities. This liaison may be required to attend Human Services
Interagency Council (HSIC) meetings if requested by LDH. The liaison shall have knowledge of the
non-Medicaid uninsured system.
o Tribal liaison that is the single point of contact regarding delivery of covered services to Native
Americans.
o Behavioral health consumer and family organizations liaison for children, youth and adults. This
person shall be a peer, former consumer of services and/or in recovery. This liaison shall be
engaged with the advocacy community.
o A Permanent Supportive Housing (PSH) program liaison, to be approved by LDH, to work with LDH
PSH program staff to ensure effective implementation of PSH program deliverables.
o An Intellectual/Developmental Disability (I/DD) liaison to work with OCDD staff to ensure effective
medical and behavioral services are in place for the I/DD population. The liaison shall have
knowledge of the I/DD service delivery system.
o A liaison dedicated to ensuring MCO compliance with both the provision of supports and services
for individuals referred to and residing in Nursing Facilities (NF), as well as all activities related to
the DOJ Agreement and the My Choice Louisiana program. The liaison shall ensure compliance
with all requirements associated with these activities, including the provision of care management
and services to populations impacted through these initiatives. The liaison shall respond to
inquiries within one business day. Any change in liaison personnel shall be sent to respective
entity within 48 hours of notice to the MCO.
Liaisons to work with Regional Crisis Coalitions developed in conjunction with the Louisiana Crisis
Response System.
24-Hour Behavioral Health Crisis line staff – Whether through subcontract, if prior approved by LDH, or
direct employment, the MCO shall have an adequate number of staff to answer the behavioral health
crisis line twenty-four (24) hours per day, seven (7) days per week, with sufficient capacity to preclude the
use of answering machines, third-party answering services, and voicemail. Staff shall participate in OBH
approved trainings.
Population Health and Health Related Social Needs (HRSN) Liaisons to provide liaison activities to the
Office of Public Health (OPH) for the following activities:
o A liaison for population health and Health Related Social Needs (HRSN) activities. This person shall
be familiar with the MCO’s population health strategic plan.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 21
BUSINESS OWNERS
LDH maintains an LDH business owner listing, which is provided to the MCOs on a monthly basis via e-mail. MCOs
should distribute this listing to its staff and use it to identify the appropriate LDH contact for questions or concerns
about a specific business area or report.
LDH also maintains an MCO business owner listing, which is provided to LDH staff. MCOs should provide updated
contact information upon request by LDH.
LDH MANAGED CARE GUIDANCE
LDH may issue informational bulletins (IBs) and health plan advisories
4
(HPAs) when there is a need to
communicate immediate guidance—particularly in temporary or emergency situations (e.g., pandemics, natural
disasters). The MCO must comply with all directives contained within IBs and HPAs.
When LDH guidance necessitates a revision to the MCO’s policies, the MCO must post the updated policy to its
provider portal within four business days, or within 24 hours for policies of an emergency nature, and the MCO
must publish its updated provider manual within 30 calendar days of provider notification, unless otherwise
specified by LDH. The MCO’s provider notice and provider manual must contain the policy language rather than
refer to LDH guidance or manuals.
MCOs and subcontractors can access IBs [link] and HPAs [link
] on the LDH website.
MCO POLICY AND PROVIDER MANUAL SUBMISSION
GUIDANCE
The MCO shall submit all new or materially amended policies, procedures, and provider manuals to
. A brief description should be provided in the subject line. Submissions of materially
amended policies, procedures, and provider manuals shall include a single document containing the existing
policy, procedure, or provider manual with the proposed revisions redlined.
In accordance with La. R.S. 46:460.54, prior to approving any policy or procedure, LDH will publish the proposed
policy or procedure on the LDH website for a period of no less than 45 calendar days for the purpose of soliciting
public comments. The public comment period will not apply if LDH finds that an imminent peril to the public
health, safety, or welfare requires immediate adoption of the proposed policy or procedure. The public comment
period also will not apply for non-material revisions. A policy or procedure proposed by an MCO shall not be
implemented unless LDH has provided its express written approval to the MCO after the expiration of the public
notice period. Additionally, the MCO shall notify its network providers at least 30 calendar days prior to
4
LDH ceased the issuance of new HPAs in 2021; however, previously issued HPAs which are not retired remain valid and
relevant to MCOs.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 22
implementation of a new or revised policy or provider manual change. The public comment period and provider
notification period may not be done concurrently without prior approval from LDH.
REPORTING
The MCO shall comply with all reporting requirements established by the Contract in accordance with this Manual
and LDH-issued companion and reporting guides.
The MCO shall create deliverables which may include documents, manuals, files, plans, and reports using the
electronic formats, instructions, and timeframes as specified by LDH and at no cost to LDH.
For the purpose of assessing non-compliance actions, LDH will utilize standard rounding of percentages (i.e.,
rounding up or down to the nearest whole number). Rounding will not be applied to other units, such as
increments of time, or to the following:
Encounter data reconciliation completion percentages; and
Provider directory accuracy rates.
Certification of Data and Reports
The MCO shall ensure the accuracy, completeness, and timely submission of each report.
The MCO shall submit all data required by 42 C.F.R. § 438.604, including any additional data, documentation, or
information relating to the performance of its obligations as required by LDH and shall certify all submitted data,
documents and reports per 42 C.F.R. § 438.606. All data reported must be certified including, but not limited to,
enrollment information, financial reports, encounter data, and other information as specified within the Contract
and this Manual. The certification must attest, based on best knowledge, information, and belief as to the
accuracy, completeness and truthfulness of the documents and data. The MCO must submit the certification
concurrently with the certified data and documents. LDH will identify specific data that requires certification.
The data shall be certified by one of the following:
The MCO’s Chief Executive Officer (CEO);
The MCO’s Chief Financial Officer (CFO); or
An individual who has the delegated authority to sign for, and who reports directly to the CEO or CFO.
The MCO shall provide the necessary data extracts to LDH or its designee as required by the Contract or specified
in the Manual.
Information Related to Business Transactions
The MCO shall furnish to LDH and/or to the United States Department of Health and Human Services, information
related to significant business transactions as set forth in 42 C.F.R. § 455.105. Failure to comply with this
requirement may result in termination of the Contract.
The MCO shall submit, within 35 calendar days of a request made by LDH, full and complete information about:
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 23
The ownership of any subcontractor with whom the MCO has had business transactions totaling more
than $25,000 during the 12 month period ending on the date of this request; and
Any significant business transactions between the MCO and any wholly owned supplier, or between the
MCO and any subcontractor, during the five year period ending on the date of this request.
Report of Transactions with Parties in Interest
The MCO shall report to LDH and, upon request, to the Secretary of the Department of Health & Human Services
(DHHS), the Inspector General of the DHHS, and the Comptroller General a description of transactions with a party
in interest (as defined in Section 1318(b) of the Public Health Service Act), as required by Section 1903(m)(4)(A)
of the Social Security Act. The MCO shall make the information reported pursuant to this section available to its
enrollees upon reasonable request.
Federally qualified MCOs are exempt from this requirement. LDH may require that the information on business
transactions be accompanied by a consolidated financial statement for the MCO and the party in interest.
The business transactions that must be reported are not limited to transactions related to serving the Medicaid
enrollment. All of the MCO’s business transactions must be reported.
If the contract is renewed or extended, the MCO must disclose information on business transactions which
occurred during the prior contract period.
Staffing
The MCO must submit to the LDH the following staff-related items annually:
An updated organization chart complete with the key staff positions. The chart must include the person’s
name, title, telephone number, and portion of time allocated to the Contract, other Medicaid contracts,
and other lines of business.
A functional organization chart of the key program areas, responsibilities, and the areas that report to
each position.
A listing of all functions and their locations; and a list of any functions that have moved outside of the
state of Louisiana in the past contract year.
Health Needs Assessment
The MCO shall maintain health needs assessment (HNA) records and submit them to LDH upon request.
Encounter Data
The MCO shall comply with the required encounter data format provided by LDH. Encounter data includes claims
paid or denied by the MCO or the MCO’s subcontractors for services delivered to enrollees through the MCO
during a specified reporting period. Submissions must include, at a minimum, all enrollee encounter data,
including allowed amount and paid amount, that the State is required to report to CMS. LDH collects and uses this
data for many reasons such as: federal reporting, rate setting, risk adjustment, service verification, managed care
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 24
quality improvement program, utilization patterns and access to care, LDH hospital rate setting and research
studies.
The MCO shall accurately report, via encounter data submissions all EPSDT and well-child services, blood lead
screening access to preventive services, and any other services as required for LDH to comply with federally
mandated CMS 416 reporting requirements.
LDH may change the encounter data transaction requirements with 60 calendar days’ written notice to the MCO.
Current LDH specifications are included in the MCO System Companion Guide. The MCO shall, upon notice from
LDH, provide notice of encounter data changes to subcontractors.
Financial Reporting
The MCO shall submit to LDH unaudited quarterly financial statements and an annual audited financial statement,
using the required format provided by LDH. Quarterly financial statements shall be submitted no later than 60
calendar days after the close of each calendar quarter. Audited annual statements shall be submitted no later
than six months after the close of the MCO’s fiscal year.
The financial statements shall be specific to the operations of the MCO rather than to a parent or umbrella
organization. Audited annual statements of a parent organization, if available, shall be also submitted.
All financial reporting shall be based on generally accepted accounting principles and generally accepted auditing
standards.
Information on Persons Convicted of Crimes
The MCO shall furnish LDH information related to any person employed or contracted with the MCO convicted of
a criminal offense under a program relating to Medicare (Title XVIII), Medicaid (Title XIX), Title XX as set forth in
42 C.F.R. § 455.106, and SCHIP (Title XXI). Failure to comply with this requirement may lead to termination of the
Contract.
Errors
The MCO shall prepare complete and accurate reports and data for submission to LDH. If after preparation and
submission, an error is discovered either by the MCO or LDH; the MCO shall correct the error(s) and submit
accurate reports and data as follows:
For encounters – In accordance with the timeframes specified in the Contract and the Manual.
For all reports and other data submissions – 7 calendar days from the date of discovery by the MCO or
date of written notification by LDH (whichever is earlier). LDH may at its discretion extend the due date if
an acceptable plan of correction has been submitted and the MCO can demonstrate to LDH’s satisfaction
the problem cannot be corrected within 7 calendar days.
Failure of the MCO to respond within the above specified timeframes may result in a loss of any money due the
MCO and the assessment of monetary penalties.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 25
Submission Timeframes
The MCO shall ensure that all required deliverables, which may include documents, manuals, files, plans, and
reports are submitted to LDH in an accurate, complete, and timely manner for review and approval. The MCO’s
failure to submit the deliverables as specified may result in the assessment of monetary penalties.
LDH may, at its discretion, require the MCO to submit additional deliverables both ad hoc and recurring. If LDH
requests any revisions to the deliverables already submitted, the MCO shall make the changes and re-submit the
deliverables, according to the time period and format required by LDH. If not otherwise restricted by federal or
state laws or regulations, LDH will provide the MCO with 60 calendar day notice on changes to all on-going reports.
Unless otherwise specified in the contract, deadlines for submitting deliverables are as follows:
Monthly deliverables shall be submitted no later than the 15
th
calendar day of the following month;
Quarterly deliverables shall be submitted by April 30, July 30, October 30, and January 30, for the calendar
quarter immediately preceding the due date;
Annual reports and files, and other deliverables due annually, shall be submitted within 30 calendar days
following the 12
th
month of the contract year; except those annual reports that are specifically exempted
from this 30-calendar-day deadline by the Contract or this Manual. The Contract or this Manual will specify
the due date of any annual report it exempts from this 30-calendar-day deadline. If the Contract is
terminated early, the Contractor shall submit reports and other deliverables as specified by LDH in the
notice of termination or as otherwise provided in the Contract; and
If a due date falls on a weekend or State-recognized holiday, deliverables will be due the next business
day.
The MCO may submit deadline extension requests for LDH consideration. Requests should be made in writing,
include the reason for the delay and the anticipated delivery date, and be submitted to LDH before close of
business on the due date.
Recurring Reports
The MCO shall prepare and submit recurring reports in the format prescribed by LDH. Unless otherwise specified,
all reports shall be submitted electronically.
The Manual and related LDH Managed Care Reporting website [link
] will serve as the definitive source of all
required recurring reports.
The MCO shall refer to the LDH Managed Care Reporting website for a complete list of recurring reports, report
formats, templates, instructions, data specifications, submission timelines and locations, and other requirements.
If the Contract is terminated early, the MCO shall submit reports and other deliverables as specified by LDH in the
notice of termination, or as otherwise provided in the Contract.
Ad Hoc Reports
The MCO shall prepare and submit any other reports as required and requested by LDH, any of LDH’s designees,
the legislature, or CMS, that are related to the MCO's duties and obligations under the Contract.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 26
Ad hoc reports shall be submitted within five business days from the date of request, unless otherwise approved
by LDH.
Transparency Report
The MCO shall designate one staff member to serve as the single point of contact for all Transparency Report
requests.
The MCO shall comply with all data requests and independent surveys from LDH or its designee. The MCO shall
comply with all instructions and definitions as disseminated by LDH for transparency reporting.
Failure to comply with reporting instructions will require resubmission of data by the MCO to LDH. To validate
that the reports are submitted correctly, the MCO may be required to supply its data code upon request of LDH
or its designee. Repeat deficiencies may subject the MCO to monetary penalties at the discretion of LDH.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 27
INTEGRATION ASSESSMENT OF PHYSICAL AND BEHAVIORAL
HEALTH
Each MCO shall work with LDH to develop a plan for the MCOs to conduct annual assessments of practice
integration using the publicly available Integrated Practice Assessment Tool (IPAT) on a statistically valid sampling
of providers to include, but not be limited to, behavioral health providers and primary care providers: internists,
family practitioners, pediatrics, OB-GYNs, and any other providers that are likely to interface with behavioral
health populations. The MCO-led workgroup will identify opportunities to coordinate this effort across MCOs to
ensure comparability of results across MCOs and minimize burden on providers. The results of the initial survey
must be reported to LDH annually.
The MCO must use an integration assessment tool to self-assess annually. Those results shall also be reported
annually to LDH. The assessment should be inclusive of, but not limited to, such factors as:
Assessing enrollee and provider experiences around integrated care annually and make improvements as
appropriate.
Identifying opportunities to strengthen or complement the IPAT by identifying barriers and opportunities
in the following functional areas:
o Knowledge, attitudes and cross-training needs (e.g., assessing provider knowledge of best
practices to address non-complicated behavioral health conditions in primary care);
o Human resource needs (e.g., access to behavioral health providers at primary care clinics and
medical providers at mental health clinics);
o Access to services (e.g., laboratories for behavioral health practices);
o Existing processes for integration (e.g., joint rounds on complex medical-behavioral cases, joint
treatment team meetings, and established procedures for consultations);
o Existing tools for integration (e.g., brief screening tools, electronic health records);
o How contractors will use data from the IPAT assessment in their annual report;
Number and type of trainings on integration offered by the MCO;
The number of forums held with outcomes;
What outreach was done to promote integration, especially on the physical health side;
How many “hot spot” sources of high emergency department (ED) referrals and/or
inpatient psychiatric hospitalization have been identified;
Has the identification of these “hotspots” led to pre-emptive coordination;
What incentives are being offered to improve integration of providers and are the
incentives effective;
The status of real time consultation of primary care providers with behavioral health
professionals or psychiatrists for behavioral health issues or consultations on
medications;
The status of a single or integrated clinical documentation system;
The status of unified systems across behavioral and physical health management; and
How is the MCO addressing integration at the MCO level to include specific actions taken
and the timeline to assess integration at this level.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 28
LEGAL COMPLIANCE
This section provides additional information or guidance related to court-ordered requirements.
AJ v. LDH
This section explains the class-action lawsuit titled A.J., a minor child by and through his mother, Donnell Creppel,
et al., versus the Louisiana Department of Health, et al., 3:19-CV-00324 (hereinafter, “AJ v. LDH”) and the
implementation and operation of key provisions of the settlement agreement in that litigation. Refer to the Home
Health chapter of the Medicaid Services Manual for general policies about home health services not specific to
AJ v. LDH.
Member Class
Class members in AJ v. LDH are defined as follows: All current and future Medicaid beneficiaries under the age of
21 in Louisiana who are certified in the Children’s Choice Waiver, the New Opportunities Waiver, the Supports
Waiver, or the Residential Options Waiver who are also prior authorized to receive extended home health (EHH)
services or intermittent nursing (IN) services which do not require prior authorization but are not receiving some
or all of the hours of extended home health services or intermittent nursing services as authorized by Louisiana
Medicaid.
Litigation Summary
AJ v. LDH, filed on May 22, 2019, seeks to enforce rights under the EPSDT and reasonable promptness mandates
of Title XIX of the Social Security Act, the Americans with Disabilities Act [42 U.S.C. §12131, et seq.], and Section
504 of the Rehabilitation Act [29 U.S.C. §794] by compelling the Department to arrange for the in-home skilled
nursing care prior authorized for Medicaid-enrolled, medically fragile children. Because of their medical needs,
class members have been prior authorized to receive EHH services to be able to live in the community. Data reflect
gaps between the EHH service amounts prior authorized and the EHH service amounts actually delivered to class
members. Potential service gaps in medically necessary IN services to class members also fall under the scope of
the litigation. The suit has been settled, and the corresponding settlement agreement was approved by the court
on March 31, 2020.
Prohibited Acts
MCOs are prohibited from reducing prior approved EHH service amounts for class members to increase the
percentage of prior approved EHH services actually delivered. Such reduction in the amount of services that have
been prior approved is contrary to federal Medicaid law and would constitute a due process violation under the
United States Constitution.
Settlement Implementation
Implementation of the settlement by MCOs is discussed more fully below.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 29
Crisis Response Team
Louisiana Medicaid has established a Crisis Response Team (CRT), the primary responsibility of which is arranging
for in-home nursing services for class members when such services are unavailable through existing Medicaid
home health agencies within the class member’s LDH region. The MCO is responsible for accepting referrals from
the CRT and arranging service fulfillment. The MCOs shall respond to the CRT within two business days of receipt
of any communication, not limited to referrals. Responses to a referral shall, at a minimum, include the following:
A plan of action to resolve the obstruction to the enrollee receiving care; and
Confirmation that any outreach to any interested party has been completed.
Support coordinators or case managers have the obligation promptly to make referrals to the CRT for any class
member who, after making reasonable efforts to receive EHH or IN services:
Has received less than 90% of his or her prior approved EHH or medically necessary IN services for at least
two consecutive weeks; or
Has been unable to locate a home health provider in his or her LDH Region or has been denied enrollment
by all home health providers in his or her LDH Region; or
Is otherwise facing a serious risk of institutionalization due to lack of EHH or IN services.
In addition, when a class member is being terminated from existing EHH services where the class member’s LDH
region does not have a provider for IN services on the date that the notice of denial has been sent, the class
member must be immediately referred to the CRT via an e-mail to crisisresponseteam@la.gov
. In such situations,
a reasonable effort includes a reevaluation of whether or not the class member should have been found eligible
for EHH services.
The CRT operates in addition to, and does not replace, the responsibilities of a class member’s existing support
coordinator or case manager.
The MCO is responsible for submitting a monthly report to LDH documenting the actions taken by the MCO to
ensure service provision and fulfillment for CRT referral members. The MCO is also responsible for submitting a
monthly report detailing the hours and service provision for class members.
Class Member Denial Notices
Notices to class members denying EHH services must contain contact information for the CRT when there is an
identified need for IN services, i.e., for in-home skilled nursing services of visits with a duration shorter than three
contiguous hours per day.
Contact information for the CRT is as follows:
E-mail: crisi[email protected]
Telephone: (866) 729-0017
Additionally, in situations when a class member is being referred to the CRT due to the unavailability of a provider
for IN services concurrent with a termination from existing EHH services, the notice of denial to the class member
of the EHH services termination must also notify the class member of the referral to the CRT.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 30
Case Management
Support coordinators or case managers must document in the progress notes for each class member all prior
approved EHH or medically necessary IN services and whether those EHH or IN services are provided, as reported
by the family, including whether the family has refused the offered services and, if so, the basis for the refusal.
Additional Rate Modifiers
Louisiana Medicaid has published a Home Health Services Fee Schedule that includes modifiers with enhanced
rates for situations in which two beneficiaries are cared for simultaneously, for children in EHH with high medical
needs, for overnight shifts for EHH, for weekend shifts for EHH, for holiday shifts for EHH, and for EHH services in
rural areas. These rate modifiers may be used in applicable circumstances to provide an enhanced reimbursement
rate to home health providers in order to facilitate fully staffing prior approved EHH services for class members.
A home health agency may also submit claims using the TU modifier to identify hours for an EHH enrollee that
were paid as overtime to the nurse delivering the care. This modifier shall not require prior authorization but must
be for hours already authorized for the enrollee. When billing, this modifier may be used in addition to any other
authorized modifiers (e.g., TG) for procedure codes S9123 and S9124, but shall be paid at a minimum of 1.5 times
the base rate of the procedure code.
The use of this modifier is subject to post-payment review. The MCO shall require the home health agency to
maintain all necessary documentation to support the use of this modifier. Non-compliance with written policy
may result in recoupment and additional sanctions, as deemed appropriate by Louisiana Medicaid.
Termination
The settlement period for AJ v. LDH is scheduled to terminate on March 31, 2025, unless otherwise ordered by
the court.
Chisholm v. LDH
Class members in Chisholm v. LDH (Case 2:97-cv-03274) are defined as follows: All current and future beneficiaries
of Medicaid in the state of Louisiana under age twenty-one who are now on or will in the future be placed on the
Developmental Disabilities Request for Services Registry.
The MCO shall comply with all court-ordered requirements as directed by LDH, including, but not limited to,
guidance provided in the Chisholm Compliance Guide and accompanying MCO User Manual.
DOJ Agreement
The target population of the Department of Justice (DOJ) Agreement (Case 3:18-cv-00608, Middle District of
Louisiana) are defined as follows: (a) Medicaid-eligible individuals over age 18 with serious mental illness (SMI)
currently residing in nursing facilities; (b) individuals over age 18 with SMI who are referred for a Pre-Admission
Screening and Resident Review (PASRR) Level II evaluation of nursing facility placement during the course of this
Agreement, or have been referred within two years prior to the effective date of this Agreement; and (c) excludes
those individuals with co-occurring SMI and dementia, where dementia is the primary diagnosis.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 31
The MCO shall comply with all court-ordered requirements as directed by LDH, including, but not limited to,
guidance provided in the DOJ Agreement Compliance Guide.
Monitoring of Denial Notices
LDH monitors denial and partial denial notices to ensure compliance with federal requirements regarding timely
and adequate notices of benefit determinations for prior authorized services. An auditing and monitoring process
was established following the Wells v. Gee litigation (Case 3:14-cv-00155).
As a result of the joint stipulation from the Wells v. Gee settlement, LDH developed multiple templates to help
the MCOs maintain compliance with federal requirements as it pertains to the development of denial and partial
denial notices of prior authorized services. LDH strongly encourages continued use of these templates as a
resource tool to assist with compliance. See the Resources section for a link to these templates.
PUBLIC RECORDS REQUEST PROTOCOL
LDH and MCOs agree that timely responding to public records act requests (“PRR”) is an important facet of the
LDH/MCO relationship. These protocols are designed to facilitate a collaborative approach aimed at allowing LDH
to promptly respond to these requests in accordance with Louisiana law. PRRs may be presented that call for
responses, and effort to create these responses, that range from simple to complicated. LDH and MCOs agree that
collaborative cooperation founded upon early and frequent communications between both sides can be helpful.
These communications could serve to refine a request to the necessary records and to produce accurate
responses. Such discussions are especially useful when such requests appear to be large, to be vague or confusing,
to seek information that does not exist as requested, or to present other challenges that could impact response
times. LDH and MCOs shall utilize these Protocols to produce streamlined, accurate and timely responses to PRRs.
Receipt of Potential Public Records Request
When LDH receives a request that may be a PRR, the Department will initiate contact with the MCO(s) that may
have documents potentially responsive to the request. This will provoke a dialogue between the LDH legal team
and MCO legal representatives where questions concerning the Request and potential responses can be
addressed. The Parties agree to early and frequent communications regarding PRRs. These discussions would also
allow for questions as to whether the document(s) being sought is, in fact, a public record.
Public Records Request (PRR) Points of Contact for LDH and
MCOs
The MCO shall provide LDH with the name of the individual who will serve as the point of contact for handling
PRRs within seven calendar days of request. If this point of contact changes at any time, the MCO shall provide
LDH with an updated contact immediately.
LDH’s point of contact for handling MCO-related PRRs is the Medicaid Public Records Request Coordinator.
MCO Manual | ADMINISTRATION & CONTRACT MANAGEMENT 32
Transmission of the Public Records Request
Upon receipt of a PRR, LDH will determine if the response requires records from the MCO. If LDH believes the
MCO has records responsive to a PRR, LDH shall notify the MCO of the PRR, and shall forward an exact copy of the
request in its entirety via e-mail to the MCO’s point of contact for handling PRRs within one business day of receipt.
If the MCO receives a PRR directly from a requesting party, the MCO shall forward the request via e-mail to the
Medicaid Public Records Request Coordinator within one business day of receipt.
In no event shall the MCO directly respond to the requesting party to satisfy a PRR. Unless otherwise directed by
a court of competent jurisdiction, LDH is the party that shall provide the response to each PRR.
If the MCO believes the records are not public and/or meet an exception to the Louisiana Public Records law, the
MCO shall produce a log that describes each document or document type that is being withheld and shall describe
the specific objection and legal basis for the withholding, pursuant to the timeline and in the requested format
established by LDH. LDH and MCO agree that the MCO is only obligated to provide documents responsive to its
Medicaid Managed Care product.
Process for LDH to Evaluate Whether Records are Subject to the
Louisiana Public Records law
Upon receipt of objection from MCOs, LDH and MCO shall confer at a mutually convenient time with due
consideration to legal restraints for compliance with Public Records Law. LDH Legal will review the objections, and
confer with the Medicaid Public Records Request Coordinator, as necessary, to address MCOs objections. LDH and
MCO will confer regarding response to the PRR, including production of documents for which no objection is
made, and alternative response, if possible, for records (e.g., redaction) for which objection is made.
Notice to MCOs of Impending Release of Records MCO has
Deemed Not Public and/or Meet an Exception to the Public
Records Law
If LDH and MCO cannot agree to the response to the PRR, LDH will provide MCO with written notice that LDH will
respond to the PRR over MCO’s objections, specifying the date on which LDH will respond, which shall not be less
than seven business days from the written notice. MCO has the right to seek injunctive or other judicial or
administrative relief to prohibit LDH’s response. If MCO elects to file a Petition for Injunctive Relief, Declaratory
Judgment or other process for judicial or administrative relief, MCO will promptly deliver a copy of the petition or
other pleading to LDH, and thereafter shall keep LDH notified of any significant developments that would impact
LDH’s obligations under Public Records laws. LDH and MCO shall cooperate as necessary any such judicial or
administrative proceeding, and shall comply with the final judgment or other ruling or determination regarding
PRR. If MCO does not file a Petition for Injunctive Relief or seek such judicial or administrative relief as specified
above, LDH may respond to the PRR in the manner LDH determines appropriate.
MCO Manual | ELIGIBILITY & ENROLLMENT 33
PART 3: ELIGIBILITY & ENROLLMENT
The Louisiana Medicaid managed care program is comprised of mandatory and voluntary opt-in populations. LDH
is responsible for determining eligibility for enrollment in the MCO, and the MCO is required to accept these
enrollees for the provision of covered services.
The Contract identifies the populations that are eligible for enrollment in managed care and the service offerings
available to them. This Manual broadly refers to enrollees with P-linkages and B-linkages.
P-linkage: Refers to enrollment in an MCO for physical health, behavioral health, and
transportation services.
B-linkage: Refers to enrollment in an MCO for specialized behavioral health and non-
emergency medical transportation (NEMT), including non-emergency ambulance
transportation (NEAT).
Additional guidance regarding special populations and enrollment processes are provided in this section.
CERTIFICATE OF CREDITABLE COVERAGE
Certificates of Creditable Coverage, or portability letters, are written certificates issued by a health plan or health
insurance issuer to show prior healthcare coverage. LDH determines the eligibility of individuals for enrollment
into an MCO; therefore, the MCO shall direct any requests for a Certificate of Creditable Coverage to LDH.
The MCO should route enrollees to the Medicaid Recovery and Premium Assistance Unit at 225-342-8662 to
request the certificate.
NEWBORN ENROLLMENT
A woman whose basis of Medicaid eligibility is pregnancy (LaMOMS) is a mandatory enrollee in the managed care
program. When a pregnant woman chooses an MCO, she will be advised by the enrollment broker that her
newborn will be enrolled in that same MCO for, at a minimum, the month of birth.
Following birth, the mother has the option to choose a different MCO for her baby. When this happens, enrollment
in the new MCO will be effective the first day of the month after she chooses the new MCO if the choice is made
on or before the second to last working day of the month.
The MCO shall be responsible for ensuring that hospitals report the births of newborns within twenty-four (24)
hours of birth for enrolled enrollees via the LDH Self-Service Provider Portal. If the enrollee makes a PCP selection
during the hospital stay and one was not already identified, this information shall be reported to the MCO. If no
selection is made, the MCO shall provide the enrollee with a minimum of 14 calendar days after birth to select a
PCP prior to assigning one.
MCO Manual | ELIGIBILITY & ENROLLMENT 34
Hospitals will continue to report births to LDH via the Newborn Request Form via the web-based facility
notification system. Within three business days, LDH will assign the newborn a Medicaid ID number and add the
baby to the Medicaid eligibility file. On the night that the newborn is added to the Medicaid eligibility file, the
enrollee information will be sent to the enrollment broker. The enrollment broker will include the newborn on
the next daily enrollment file to the mother’s MCO and the MCO will add the newborn to their enrollee file.
Enrollment of newborns shall be retroactive to the date of the birth.
The enrollment broker will generate a confirmation letter to the mother indicating that the baby has been enrolled
in the MCO in which she is enrolled and giving her 90 days from the date of the letter to select a different MCO
for the baby if she chooses to do so.
The MCO is responsible for covering all newborn care rendered within the first month of life regardless of whether
it is provided by in an in-network or out-of-network provider.
NOTE: Primary care physician (PCP) assignment for the newborn is made by the MCO, not by LDH or the enrollment broker.
Refer to the Contract for requirements.
JUSTICE-INVOLVED ENROLLEES
LDH, in conjunction with the Department of Corrections (DOC), has developed a pre-release program for the
offender population that is covered by Medicaid under the New Adult Group through Medicaid expansion. All
justice-involved enrollees releasing from incarceration shall be enrolled in accordance with the process outlined
in the Justice-Involved Pre-Release Enrollment Program Manual.
ELIGIBILITY UPDATES
The enrollment broker shall make available to the MCO, via electronic media (i.e., ASC X12N 834 Benefit
Enrollment and Maintenance transaction), daily updates on new enrollees in the format specified in the 834
Systems Companion Guide.
In addition to the daily file, the enrollment broker shall transmit to the MCO files containing retroactive updates
to enrollment. These files will be available to download via the enrollment broker’s EDI site.
Medicaid Eligibility Determinations Based on SSI
When Supplemental Security Income (SSI) determinations are obtained by LDH from the Social Security
Administration, they may be retroactive and LDH will alter eligibility periods with the appropriate aid
category/type case information. This eligibility process may cause overlaps with existing eligibility periods for the
impacted enrollees, resulting in a need for reconciliation between LDH, the fiscal intermediary, the enrollment
broker, and the MCO.
The overlapping certification will be transmitted daily from LaMEDS to the fiscal intermediary. The fiscal
intermediary will send the overlapping eligibility information to the enrollment broker via daily enrollee files
and/or weekly full reconciliation files, and the enrollment broker will distribute to the MCOs via 834 full
reconciliation file in the 2700 Loop. All historical eligibility will be present on the file.
MCO Manual | ELIGIBILITY & ENROLLMENT 35
The fiscal intermediary will conduct a retrospective SSI cleanup on a monthly basis, with a 12-month look back
period from the beginning of the month. MCOs can identify impacted enrollees by reviewing the associated 820
file.
ADMINISTRATIVE RETROACTIVE CORRECTIONS
Administrative retroactive corrections to enrollee linkages may be necessary to ensure compliance with internal
policies and the approved Louisiana Medicaid State Plan. These corrections may address multiple months and
significantly impact paid claims and PMPMs.
Each month, LDH and its fiscal intermediary will review all changes made by the enrollment broker in the prior
month to identify retroactively enrolled or disenrolled individuals, claims paid within this retroactive period, and
associated adjustments needed to PMPMs.
LDH, or its designee, will send a monthly report of impacted enrollees to the MCOs with detailed information to
assist in anticipating claims which should be billed to them for their retroactively enrolled enrollees.
Retroactive Enrollment
An enrollee may be retroactively enrolled with an MCO up to 12 months prior to the enrollee’s MCO linkage add
date. Providers have up to 365 calendar days from the date of service or 180 calendar days from the enrollee’s
MCO linkage add date, whichever is later, to submit claims to the MCO for dates of service during the retrospective
enrollment period. The MCO linkage add date is reported on the 834 file header.
MCOs shall not deny these claims for timely filing, prior authorization or precertification edits. The provider shall
not be required to submit the enrollee’s eligibility determination award letter. Instead, the MCO shall develop a
process to bypass timely filing, prior authorization, and precertification edits using the enrollee’s MCO linkage add
date.
MCOs may conduct post-service reviews for medical necessity, and if the MCO determines the service was not
medically necessary, the MCO may deny the claim. The provider will have the right to appeal the denial.
Retroactive Disenrollment
The MCO shall review the daily 834 files and any manual special processing files provided by the enrollment broker
on a daily basis to identify whether any of its enrollees were retroactively disenrolled. The MCO shall identify all
associated claims which were paid for these enrollees.
If the enrollee was retroactively disenrolled due to the invalidation of a duplicate Medicaid ID and the remaining
valid ID is linked to another MCO, in accordance with the Contract, the MCO shall subrogate the amount of the
paid claims to the MCO that paid the claims for the dates of service.
If the enrollee was retroactively disenrolled for any other reason, the MCO shall:
Initiate recoupments of reimbursements to providers, via written notice, within 60 days of the date LDH
notifies the MCO of the change.
MCO Manual | ELIGIBILITY & ENROLLMENT 36
Require providers to submit paper/hard copy claims to the correct entity, unless the MCO has established
other means of identifying these claims.
o Providers shall not be required to obtain prior authorization or pre-certification for these claims.
o Providers must attach documentation supporting the void. This may be the remittance advice (RA)
indicating the void.
o The MCO shall not deny claims submitted in cases of retroactive eligibility for timely filing if the
claim is submitted within 180 days from the enrollee’s linkage to the MCO.
The exception to the retroactive eligibility timely filing requirements are such that the
claim must be submitted to the MCO by the latter of 365 calendar days from the date of
service or 180 days from the enrollee’s linkage to the MCO.
Submit encounters for voided claims to the fiscal intermediary.
Refer to the Contract for additional requirements related to provider recoupments, including provider notification
requirements.
ENROLLEE RETROACTIVE REIMBURSEMENT
The MCO is responsible for processing retroactive reimbursement requests submitted by Medicaid enrollees.
Medicaid enrollees may be directly reimbursed for part or all of any medical expenses paid by them to any
Medicaid provider for medical care, services, and supplies delivered during the period of retroactive eligibility and
prior to the expected date of receipt of the MCO’s ID card and/or expected date of receipt of notification of linkage
to the MCO. Value-added benefits offered by the MCOs are not eligible for reimbursement.
The MCO must have written policies and procedures for receiving, processing, and issuing payment for enrollee
retroactive reimbursement requests and a tracking system that can be accessed by its member services staff.
The MCO shall provide customer service to enrollees who seek explanations and/or education regarding
retroactive reimbursement issues.
The MCO must use claims payment business processes that deny or approve requests for retroactive
reimbursement. For approved requests, the business processes must be able to do the following: edit, adjudicate,
adjust, void, pay, and audit the request for reimbursement of covered Medicaid services. In cases of a retroactive
reimbursement involving third party liability, the MCO may instruct the provider to resubmit the unpaid portion
of the claims to the MCO for payment, if applicable.
MCOs must provide written notice of eligibility for retroactive reimbursement information in an enrollee welcome
letter. The welcome letter must include the following policies and provide the date the request is due:
Enrollees are eligible for reimbursement of medical expenses paid three months prior to the month of
application if they requested retroactive coverage on their application and received approval.
Enrollees are given 30 calendar days from the date of the welcome letter to contact the MCO to request
consideration for reimbursement and provide the required documentation.
An extension of up to 10 calendar days shall be granted if the extension is requested on or before the
deadline. A second extension of no more than 10 additional calendar days should be granted if the
extension is requested before the deadline of the first extension. No extensions shall be granted beyond
this timeframe.
MCO Manual | ELIGIBILITY & ENROLLMENT 37
Changes to existing documents (e.g., policies, welcome letter templates) must be reviewed and approved by LDH
in advance.
Reimbursement Criteria
Reimbursement shall be provided only under the following conditions:
The enrollee is Medicaid eligible for the date of service.
The MCO has verified that the provider is enrolled with the MCO on the date on which the enrollee
received the service and is approved to provide the service rendered.
The bills must be for services received on or after the Medicaid effective date through receipt of the initial
Medicaid eligibility card (MEC) or reactivation of the MEC. Reactivation of the MEC would take place when
an enrollee of Medicaid status has an interruption in coverage, reapplies and is certified for coverage in a
qualifying Medicaid program. The certification period is usually twelve months.
The enrollee has not received reimbursement from Medicaid or the Medicaid provider or received
payment in full by a third-party entity.
The medical bills must be for medical care, services, or supplies covered by Medicaid at the time that the
service was delivered.
The enrollee must provide proof of payment to the MCO. Bills which were paid in full by a third party (e.g.,
Medicare, an insurance company, charitable organization, family, or friend) cannot be considered for
reimbursement unless the enrollee remains liable to the third party. It is a requirement that continuing
liability of the enrollee be verified.
Bills Not Eligible for Reimbursement
Unpaid bills - the enrollee should present his or her MEC to the provider along with the unpaid bill so that
the provider can file a claim.
Bills paid by the enrollee after receipt of the initial MEC or reactivation of the MEC.
Bills paid to a non-Medicaid provider who does not participate in the Medicaid Program.
DME purchased without documentation of medical necessity.
Over-the-counter medications or supplies purchased without a prescription.
Value-added benefits offered by the MCO.
Reimbursements Involving Third Party Liability
The MCO should use a cost comparison method for enrollee reimbursement requests involving third-party liability
(TPL). The claim must first be processed by the primary payer. The TPL payment amount is provided on the
explanation of benefits (EOB) sent by the primary payer. The reimbursement to the enrollee shall be the Medicaid
allowed amount minus the TPL payment. If the TPL payment is greater than the Medicaid allowed amount, the
reimbursement to the enrollee would be zero.
The MCO shall require enrollees to submit all of the required documentation listed below within the timeframes
specified above.
MCO Manual | ELIGIBILITY & ENROLLMENT 38
Required Documentation
An enrollee seeking reimbursement must provide to the MCO a copy of the bill(s) or other acceptable verification
which include(s) the following:
Name of the individual who received the service,
Name, address and phone number of the physician or facility providing the service,
Date of service,
Procedure and Diagnosis codes,
Amount of billed charges and verification of payment,
Receipts or other acceptable proof showing that the bill was paid by the Medicaid enrollee or someone
else. If paid by someone else, proof that the eligible is still liable for repayment to the individual who paid
the bill,
Proof of payment by any Private Insurance - EOB, and, if applicable,
If Durable Medical Equipment (DME) - dates of service, quantity, diagnosis and procedure codes,
documentation of medical necessity from the provider, amount billed, amount enrollee paid, and
verification of private insurance payments (EOB).
If Dental - diagnosis and procedure codes per tooth.
If Pharmacy - date prescription was filled, National Drug Code (NDC), quantity dispensed, and retail cash
price if insurance or discount card was used or the amount paid by the third-party entity.
If the MCO determines that additional information is needed from the enrollee, the MCO shall mail a Recipient
Verification Request Form to the enrollee within three business days of the receipt of the initial request.
The enrollee shall be allowed 15 days to provide the additional documentation and, upon request for additional
time, be granted an extension. If an extension is requested, no more than 15 additional days shall be granted.
Enrollees who fail to provide the requested documentation or fail to request an extension shall have the request
for reimbursement denied.
Processing Timeframes
MCOs must follow established timeframes as required by the Contract. A reimbursement request is considered
clean when the enrollee has timely submitted all requested documentation within the established timeframe;
therefore, the MCO shall process the request within three months from the date of the request and mail a Notice
of Decision Letter to the enrollee. If the request is denied, the notice must include a clear explanation of the
reason(s) for ineligibility for reimbursement.
Requests received by the MCOs for reimbursement of payment for carved-out services must be submitted to LDH
within five business days of receipt for processing by LDH.
MANAGED CARE LINKAGE FOR LONG TERM CARE
ENROLLEES
A managed care enrollee with a P-linkage who is subsequently certified in long term care (LTC) will be disenrolled
from the P-linkage effective the last day of the month during which the enrollee is admitted to the nursing facility.
MCO Manual | ELIGIBILITY & ENROLLMENT 39
As eligibility dictates, the enrollee will be enrolled in a B-linkage effective the first day of the month following the
enrollee’s LTC certification.
This will provide continuity of care for enrollee’s transitioning from post-acute skilled nursing facility rehabilitative
care into LTC. This will also stabilize claims and reimbursement responsibilities.
Claims Responsibility
During the single transitional month where an enrollee is both in a P-linkage and certified in LTC, the MCO remains
responsible for all managed care physical and behavioral health services that are not the responsibility of the
nursing facility.
MCOs must have appropriate edits in place to ensure that they are not reimbursing the nursing facility for post-
acute skilled nursing services under their “in lieu of” authority after the LTC certification begins.
The MCO will receive the LTC begin and end date and the nursing facility admit and discharge date on the 834 file
(loop 2300 at HD03).
Medicaid fee-for-service (FFS) will maintain responsibility for nursing facility charges for LTC certified members
(i.e., after the LTC begin date). The nursing facility, as provided for in the Louisiana Administrative Code, Title 50,
Public Health - Medical Assistance, will be responsible for billing nursing facility covered services to FFS.
MCOs shall ensure that physician services are not reimbursed by the MCO after the LTC begin date as these are
paid for in the per diem reimbursed by Medicaid FFS. Specifically, excluded physician services after the LTC
certification begins include, but are not limited to, the following:
Physician claims (claim type 04) for Personal Care Services (type of service is 10, procedure code is T1019
with a ‘”UB,” “UN” or “UP” modifier) for an enrollee that is linked to a LTC facility as of the date of service.
Physician, Professional Crossover, or DME claims (claim type 04, 09 or 15) for a primary surgical dressing
kit (procedure code is A4555) for an enrollee that is linked to a LTC facility as of the date of service.
Physician claims (claim type 04) for medication monitoring or administration (procedure codes H0033,
H0034, T1502, T1503) for an enrollee that is linked to a SNF, ICF-I, ICF-II or Community Hospice LTC facility
(level of care is 20, 21, 22 or 88) as of the date of service.
Physician claims (claim type 04) for therapy, evaluation or consultation services (procedure codes 97597,
97598, 97602, 97605-97608, 97610, 97113, 97161-97164, 97165-97168, 97169-97172, 92521-92522,
92523, 92524, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 92526, 97010, 97012, 97014,
97016, 97018, 97022, 97024, 97026, 97028, 97032-97039, 97760-97762, 97764, 97799, 97082-97084,
98925-98929, 98941-98943, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161,
G0162) for an enrollee that is linked to an ICF/IID LTC facility (level of care is 26, 41, 42, 43 or 44) as of the
date of service.
Physician claims (claim type 04) for certain first aid supplies (procedure codes A4244, A4246, A4204,
A4454, A4200, A4202, A4205, A4555, A4357, A5114, B4081) for an enrollee that is linked to a LTC facility
that is not an Adult Day Care (level of care is not 27) as of the date of service.
MCO Manual | ELIGIBILITY & ENROLLMENT 40
Disenrollment Notification
P-linkage disenrollment information and B-linkage enrollment will be transmitted to the MCO in the daily 834 file
with disenrollment codes 931 and 932.
Code 931 example:
o Enrollee has an 8/1/2017 plan start date with a P-linkage.
o Enrollee was certified in LTC with a 7/2/2017 date of admission.
o Code 931 will be used to void the 8/1/2017 plan start date and transfer the enrollee into B-linkage
with an 8/1/2017 plan start date.
Code 932 example:
o Enrollee has a 2/1/2016 plan start date with a P-linkage.
o Enrollee was certified in LTC with an 8/2/2017 date of admission.
o Code 932 will be used to close the 2/1/2016 plan start date with an 8/31/2017 end date and
transfer the enrollee into B-linkage with a 9/1/2017 plan start date.
MCO Manual | SERVICES | MCO Covered Services 41
PART 4: SERVICES
The Louisiana Medicaid State Plan establishes the services covered as well as reimbursement methodologies for
Medicaid FFS. State Plan services are broad categories (e.g., physician services, hospital services), and the
Medicaid FFS fee schedule operationalizes that coverage. In accordance with 42 C.F.R. § 438.210, the MCO must
provide for coverage of services that is no more restrictive in amount, scope, and duration than is covered in
Medicaid FFS.
Compared with Medicaid FFS, the MCO has the flexibility to cover services in a greater amount, scope, or duration,
or to an expanded patient group, if deemed medically necessary. Nothing herein shall be construed by the MCO
to limit coverage to only those procedure codes listed on the Medicaid FFS fee schedules. Within the broad State
Plan categories, the MCO has the flexibility to reimburse for procedure codes not on the Medicaid FFS fee
schedules when medically necessary. For those services not covered under the State Plan, the Contract identifies
requirements for in-lieu-of services and value-added benefits that the MCO may offer. The MCO shall consult LDH
with any questions about these requirements.
Further, federal law mandates that enrollees under 21 years of age are entitled to receive all medically
necessary health care, screening, diagnostic services, treatment, and other measures to correct or improve
physical or mental conditions (Section 1905(r) of the Social Security Act). The Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) benefit is comprehensive in nature and includes coverage of all services
described in federal Medicaid statutes and regulations including those that are not covered for adults, not
explicitly described in the Contract, not included in the Medicaid FFS fee schedules, and not covered in the
Louisiana Medicaid State Plan. The MCO shall consult LDH with any questions about these requirements.
This section defines minimum coverage and reimbursement policies for select services only and does not
represent an exclusive list of covered services. Unless otherwise agreed to by the MCO and its contracted
providers, the Medicaid FFS fee schedule establishes the minimum reimbursement rates for services rendered to
enrollees. Any references herein to a minimum reimbursement rate shall include the exception that the MCO may
contract with its providers to reimburse the service at a lower rate, if the contracting parties agree.
The MCO shall develop and maintain comprehensive provider manuals customized to the Louisiana Medicaid
managed care program that are in alignment with this Manual and inclusive of all applicable MCO-established
policies. The MCO shall not include references to the Medicaid Services Manual or this Manual in lieu of
maintaining its own comprehensive provider manuals. The MCO shall make coverage decisions in alignment with
its own provider manuals, with the policies in this section, and with the Contract.
The MCO shall update its provider manuals in a timely manner and be responsive to provider questions or
concerns.
MCO COVERED SERVICES
Services for which LDH has established specific minimum coverage and reimbursement policies are noted below
with an asterisk (*) when included in this Manual. Outside of this Manual, certain services for which LDH has
established minimum coverage and reimbursement policies are located in the Medicaid Services Manual, as
notated below. Policies for in-lieu of services and value-added benefits are not included in this section.
MCO Manual | SERVICES | MCO Covered Services 42
Physical Health Services
o Advanced Practice Registered Nurses*
o After Hours Care on Evenings, Weekends, and Holidays*
o Allergy Testing and Allergen Immunotherapy*
o Ambulatory Surgical Services*
Ambulatory Surgical Centers (Non-Hospital)*
Outpatient Hospital Ambulatory Surgery*
o Anesthesia*
o Applied Behavior Analysis Therapy (age 0-20) (Refer to Medicaid Services Manual, Applied
Behavior Analysis)
o Assistant Surgeon/Assistant at Surgery*
o Audiology Services
o Bariatric Surgery*
o Breast Surgery*
o Cardiovascular Services*
o Chiropractic Services* (age 0-20)
o Cochlear Implant* (age 0-20)
o Community Health Workers*
o Concurrent Care – Inpatient*
o Diabetes Self-Management Training*
o Durable Medical Equipment, Prosthetics, Orthotics and Certain Supplies (Refer to Medicaid
Services Manual, Durable Medical Equipment)
o Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Services* (age 0-20)
o Emergency Services*
o End Stage Renal Disease Services (Refer to Medicaid Services Manual, End Stage Renal Disease)
o Eye Care and Vision Services*
o Family Planning Services*
o Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) Services (Refer to Medicaid
Services Manual, Federally Qualified Health Centers, Rural Health Clinics)
o Genetic Counseling and Testing*
o Glasses, Contacts, and Eye-Wear (Refer to Medicaid Services Manual, Vision)
o Gynecology*
o Home Health-Extended Services (age 0-20) (Refer to Medicaid Services Manual, Home Health)
o Home Health Services*
o Hospice Services (Refer to Medicaid Services Manual, Hospice)
o Hospital Services*
Inpatient Hospital Services*
Outpatient Hospital Services*
o Hyperbaric Oxygen Therapy*
o Immunizations*
o “Incident to” Services*
o Intrathecal Baclofen Therapy*
o Laboratory Services*
o Limited Abortion Services*
MCO Manual | SERVICES | MCO Covered Services 43
o Medical Transportation Services*
o Newborn Care and Discharge*
o Obstetrics*
o Organ Transplants*
o Pediatric Day Healthcare Services (age 0-20) (Refer to Medicaid Services Manual, Pediatric Day
Health Care)
o Personal Care Services* (age 0-20) (Refer to Medicaid Services Manual, Personal Care Services.
Refer to this Manual for policies specific to EVV.)
o Pharmacy Services*
o Physician Administered Medication*
o Physician Assistants*
o Physician/Professional Services*
o Podiatry Services
o Portable X-Ray Services*
o Preventive Services for Adults* (age 21 and older)
o Radiology Services*
o Routine Care Provided to Enrollees Participating in Clinical Trials*
o Sinus Procedures*
o Skin Substitutes for Chronic Diabetic Lower Extremity Ulcers*
o Sterilization*
o Telemedicine/Telehealth*
o Therapy Services*
o Tobacco Cessation Services
o Vagus Nerve Stimulators*
Behavioral Health Services
o Basic Behavioral Health Services*: Services provided through primary care, including, but not
limited to, screening for mental health and substance use issues, prevention, early intervention,
medication management, and treatment and referral to specialty services.
o Specialized Behavioral Health Services (Refer to the Behavioral Health Services Provider Manual
chapter of the Medicaid Services Manual and its appendices for all specialized behavioral health
services.)
Licensed Practitioner Outpatient Therapy
• Parent-Child Interaction Therapy (PCIT)
• Child Parent Psychotherapy (CPP)
• Preschool PTSD Treatment (PPT) and Youth PTSD Treatment (YPT)
• Triple P Positive Parenting Program
• Trauma-Focused Cognitive Behavioral Therapy
• Eye Movement Desensitization and Reprocessing (EMDR) Therapy
• Dialectical Behavior Therapy (DBT)
Mental Health Rehabilitation Services
• Community Psychiatric Support and Treatment (CPST)
• Evidence-Based Programs (EBPs) specialized for high-risk populations, including:
o Multi-Systemic Therapy (MST) (age 0-20)
MCO Manual | SERVICES | Ambulatory Surgical Services 44
o Functional Family Therapy (FFT) and Functional Family Therapy-Child
Welfare (age 0-20)
o Homebuilders® (age 0-20)
o Assertive Community Treatment (age 18 and older)
• Psychosocial Rehabilitation (PSR)
• Crisis Intervention
• Crisis Stabilization for Youth (age 0-20)
• Crisis Response Services:
• Mobile Crisis Response (MCR) (age 21 and over)
o Ages 0-20, effective April 1, 2024
• Community Brief Crisis Support (CBCS) (age 21 and over)
o Age 0 – 20, effective April 1, 2024
• Behavioral Health Crisis Care (BHCC) (age 21 and over)
• Crisis Stabilization for Adults (age 21 and over)
Peer Support Services (ages 21 and older)
Therapeutic Group Homes (TGH) (age 0-20)
Psychiatric Residential Treatment Facilities (PRTF) (age 0-20)
Inpatient Hospitalization (age 0-21; 65 and older)
Outpatient, Residential, and Inpatient Substance Use Disorder Services
Opioid Treatment Programs (OTPs)
Behavioral Health Personal Care Services for DOJ Agreement Target Population
Individual Placement and Support (IPS) Services for DOJ Agreement Target Population
Out-of-State Medical Care
The MCO shall cover medically necessary services to enrollees provided outside of the state when any of the
following conditions are met:
Medical services are needed because of a medical emergency;
Medical services are needed and the enrollee’s health would be endangered if the enrollee were required
to travel to the enrollee’s state of residence;
The MCO determines, on the basis of medical advice, that the needed medical services, or necessary
supplementary resources, are more readily available in the other state; or
It is general practice for enrollees in a particular locality to use medical resources in another state.
The MCO shall prior authorize all non-emergency out-of-state care.
AMBULATORY SURGICAL SERVICES
The MCO shall cover ambulatory surgical services, defined as surgical services where patients do not require
hospitalization and in which the expected duration of services would not exceed 24 hours. Ambulatory surgical
services can be provided in non-hospital ambulatory surgical centers and outpatient hospitals.
MCO Manual | SERVICES | Ambulatory Surgical Services 45
Ambulatory Surgical Centers (Non-Hospital)
Covered Services
The MCO shall cover medically necessary, preventive, diagnostic, therapeutic, rehabilitative or palliative services
furnished to an outpatient by or under the direction of a physician or dentist in a free-standing facility which is
not part of a hospital but which is organized and operated to provide medical care to enrollees.
ASC services are items and services furnished by an outpatient ASC in connection with a covered surgical
procedure. Covered services include, but are not limited to the following:
Nursing, technician, and related services;
Use of an ambulatory surgical center;
Lab and radiology, drugs, biologicals, surgical dressings, splints, casts, appliances, and equipment directly
related to the provision of the surgical procedure;
Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;
Administrative, record keeping, and housekeeping items and services;
Materials for anesthesia;
Intraocular lenses; and
Supervision of the services of an anesthetist by the operating provider.
Exclusions
ASC services do not include items and services for which reimbursement may be made under other, separate,
programs. ASC services do not include:
Professional services;
Lab and radiology services not directly related to the surgical procedure;
Diagnostic procedures (other than those directly related to performance of the surgical procedure);
Prosthetic devices (except intraocular lens implants);
Ambulance services;
Leg, arm, back, and neck braces;
Artificial limbs; and
Durable medical equipment for use in the enrollee’s home.
Provider Requirements
The MCO shall ensure that ASCs have an agreement with the Centers for Medicare and Medicaid Services (CMS)
in accordance with 42 C.F.R. § 416.30 and that ASCs are licensed and certified by Louisiana’s licensing and
certification agency.
The MCO’s policy shall include the directive that the ASC must have a system to transfer enrollees requiring
emergency admittance or overnight care to a fully licensed and certified hospital following any surgical procedure
performed at the facility.
MCO Manual | SERVICES | Ambulatory Surgical Services 46
Reimbursement
The MCO shall reimburse ASCs a flat fee per service. The minimum reimbursement shall be in accordance with
the four payment groups specified in the Louisiana Medicaid Ambulatory Surgical Centers (Non-Hospital) Fee
Schedule.
The flat fee reimbursement is for facility charges only, which covers all operative functions associated with the
performance of a medically necessary surgery while the enrollee is in the center including the following:
Admission;
Patient history and physical;
Laboratory tests;
Operating room staffing;
Recovery room charges; and
All supplies related to the surgical care of the enrollee and discharge.
The flat fee excludes reimbursements for professional services (e.g., the provider performing the surgery, dentists,
anesthesiologists, radiologists, or osteopaths).
For those surgical procedures not included in the payment groupings, the minimum reimbursement is the flat fee
for the service specified on the Louisiana Medicaid Ambulatory Surgical Centers (Non-Hospital) Fee Schedule.
Only one procedure code may be reimbursed per outpatient surgical session.
Outpatient Hospital Ambulatory Surgery
The MCO shall cover certain ambulatory surgical procedures if they are performed in the outpatient hospital
setting. The MCO shall reimburse hospitals for the performance of these outpatient surgical procedures on a flat-
fee per service basis.
The MCO shall require hospitals to bill all outpatient surgery charges for the specified surgeries using revenue
code “490” — Ambulatory Surgery Care. All other charges associated with the surgery (e.g., observation, labs,
radiology) must be billed on the same claim as the ambulatory surgery charges. The only revenue code that will
be paid will be the flat rate fee for the ambulatory surgery. The minimum reimbursement rate for groupings can
be found on the Louisiana Medicaid Outpatient Hospital Ambulatory Surgery Fee Schedules. A list of the surgical
procedures is also provided on the fee schedule.
For minor surgeries that are medically necessary to be performed in the hospital operating room but the
associated CPT code is not included in the Louisiana Medicaid Outpatient Hospital Ambulatory Surgery Fee
Schedules, the MCO shall require hospitals to bill using revenue code HR361 - Operating Room Services-Minor
Surgery.
When more than one surgical procedure is performed on the same date of service, the MCO shall pay only the
primary surgical procedure.
MCO Manual | SERVICES | Behavioral Health Services 47
BEHAVIORAL HEALTH SERVICES
Basic behavioral health services are mental health and substance use services which are provided to enrollees
with emotional, psychological, substance use, psychiatric symptoms and/or disorders that are provided in the
enrollee’s primary care physician (PCP) office by the enrollee’s PCP as part of primary care service activities.
Specialized behavioral health services are mental health services and substance use/addiction disorder services,
specifically defined in the Louisiana Medicaid State Plan and/or applicable waivers. These services are
administered under LDH authority in collaboration with the MCOs, as well as through the Coordinated System of
Care (CSoC) program contractor, for CSoC enrollees. The MCO shall comply with the Behavioral Health Services
Provider Manual chapter of the Medicaid Services Manual.
The MCO shall screen enrollees to determine level of need for the purpose of service authorization based on
medical necessity. Based on this medical necessity determination, the MCO shall authorize specialized behavioral
health services as appropriate.
Services shall be managed to promote utilization of best, evidence-based and informed practices and to improve
access and deliver efficient, high quality services.
Criteria for screening protocols and determining whether an individual meets the criteria for specialized
behavioral health services may be determined by LDH and are based on factors relating to age, diagnosis, disability
(acuity) and duration of the behavioral health condition.
For individuals screened and considered to be in need of substance use services, the ASAM 6 Dimension risk
evaluation shall be used to determine appropriate placement in substance use withdrawal management or
treatment levels of care.
Screening for services, including the Coordinated System of Care, shall take place while the youth resides in a
home and community-based setting and is at risk for hospital levels of care. The MCO shall ensure (either using
care management protocols or by ensuring appropriate, proactive discharge planning by contracted providers)
the screening takes place while a youth resides in an out-of-home level of care (such as inpatient, PRTF, SUD
residential treatment or TGH) and is prepared for discharge to a home and community-based setting. For settings
such as PRTF and TGH with lengths of stay allowing sufficient time for comprehensive and deliberate discharge
and aftercare planning, the MCO shall ensure that screening for CSoC takes place at least 30 days and up to 90
days prior to the anticipated discharge date. If CSoC screening shows appropriateness, referral to CSoC up to 90
days prior to discharge from a residential setting shall occur, as it is expected to assist in comprehensive discharge
and treatment planning, prevent disruption, and improve stabilization upon reentry to a home and community
environment.
Emergency Certificates for Inpatient or Residential Behavioral
Health Services
This section provides guidance relative to implementation of Act 390 of the 2015 Regular Legislative Session
relative to reimbursement for inpatient/residential behavioral health services for persons admitted to treatment
under an emergency certificate. Emergency certificates are inclusive of Physician’s Emergency Certificates,
Coroner’s Emergency Certificates, and Judicial Certificates.
MCO Manual | SERVICES | Behavioral Health Services 48
The MCO is required to pay claims for behavioral health services provided to enrollees committed under an
emergency certificate to an inpatient or residential facility regardless of medical necessity. This payment
requirement shall be for a maximum period of 24 hours from the time of admission to the inpatient or residential
facility, as long as the following conditions are met:
The admitting physician and the evaluating psychiatrist or medical psychologist shall offer the subject of
the emergency certificate the opportunity for voluntary admission; and
Any person committed under an emergency certificate shall be evaluated by a psychiatrist or medical
psychologist in the admitting facility within 24 hours of arrival at the admitting facility.
After the psychiatric evaluation has been completed, payment of claims shall be determined by medical necessity.
If the subject of the emergency certificate does not receive a psychiatric evaluation within the required timeframe,
the MCO is only required to pay behavioral health claims within the first 24 hours of admission. Payment for any
subsequent claim shall be determined by medical necessity.
Reimbursement under this Act is limited to behavioral health claims and usual and customary laboratory services
necessary to monitor patient progress. The MCO is not responsible for payment of non-behavioral health service
claims which fail to meet medical necessity criteria.
Refer to the following links for statutory requirements for admission by emergency certificate or judicial
commitment and voluntary admission:
Admission under emergency certificate [link
]
Judicial commitment [link]
Formal voluntary admission [link]
Forms for emergency certificates, judicial commitments, and voluntary admissions are promulgated through the
Office of Behavioral Health on the LDH website [link
] as follows:
OBH 1 – Physician’s emergency certificate
OBH 1A – Psychologist’s emergency certificate
OBH 2 – Coroner’s emergency certificate
OBH 11 – Petition for judicial commitment (hospital/facility)
OHB 143 – Physician’s certificate for minors
OBH 7 - Formal voluntary admission
Pre-Admission Screening and Resident Review
All persons seeking admission to a Medicaid certified nursing home are required to complete a preadmission
screen (PAS/Level I) prior to admission and send it to LDH’s Office of Aging and Adult Services (OAAS). Those
identified as suspected of having a mental illness are referred by OAAS to the Office of Behavioral Health (OBH)-
Pre-Admission Screening and Resident Review (PASRR) for a Level II determination.
OBH-PASRR refers all enrollees for an independent evaluation to their respective MCO if a face-to-face evaluation
was deemed necessary to determine the enrollee’s need for nursing home admission and services. MCOs shall
adhere to the contract requirements related to the staffing and implementation of the PASRR Level II evaluation
process.
MCO Manual | SERVICES | Behavioral Health Services 49
In accordance with PASRR operations, MCOs must submit the PASRR Level II evaluation to OBH-PASRR for a final
determination. Complete and thorough Level II evaluations should be submitted to OBH-PASRR and should include
the following information:
A comprehensive history and physical that includes complete medical history; review of all bodily systems;
specific evaluations of the person's neurological system in the areas of motor functioning, sensory
functioning, gait, deep tendon reflexes, cranial nerves and abnormal reflexes; and in the case of abnormal
findings which are the basis of nursing home placement, additional evaluations conducted by appropriate
specialists.
A comprehensive drug history including current or immediate past use of medications that could mask
symptoms or mimic mental illness, side effects or allergies.
A psychosocial evaluation.
A comprehensive psychiatric evaluation including a complete psychiatric history; evaluation of intellectual
functioning, memory functioning and orientation; description of current attitudes and overt behaviors,
affect, suicidal or homicidal ideation, paranoia and degree of reality testing (presence of content of
delusions); and hallucinations.
Records that speak to the reason for nursing home placement, including documentation to support
categorical determinations (i.e., terminal illness, severe physical illness, or any illness where the individual
is not likely to benefit from a specialized behavioral health service).
If there is an indication of dementia within the records, include corroborative testing or other information
available to verify the presence of progression of the dementia (i.e., dementia work up, Comprehensive
Mental Status Exam).
MCOs should ensure the appropriate linkage of individuals referred through the PASRR Level II process to case
management and services regardless of the final determination of placement into a nursing facility, in accordance
with processes outlined within the DOJ Compliance Guide. Additionally, the MCOs shall maintain appropriate
records and utilize the LDH-identified templates.
Specialized Behavioral Health Evidence-Based Practice
Programs
The providers of Functional Family Therapy (FFT), Multi-Systemic Therapy (MST), Homebuilders and Assertive
Community Treatment Act (ACT), and Individual Placement and Support (IPS) maintain fidelity monitoring as part
of their certification/credentialing process. The MCO shall maintain Memorandums of Understanding (MOUs)
with the fidelity monitoring agencies for FFT, MST, and Homebuilders. The MOUs outline a collaborative protocol
between the MCO and the monitoring agencies to ensure the appropriate exchange of fidelity reports and other
quality reports.
The MCO shall manage the fidelity monitoring process for ACT and IPS providers to ensure at least minimum
fidelity standards are met utilizing the LDH-specified ACT monitoring tool and the IPS Fidelity Scale. The MCO shall
utilize a fidelity-monitoring process agreed upon across MCOs and LDH to ensure a single process is implemented
for providers across networks. Additionally, MCOs shall ensure their staff are properly trained on utilization of the
identified ACT and IPS monitoring tools in order to appropriately evaluate the provider’s adherence to best
practices.
MCO Manual | SERVICES | Emergency Services 50
EMERGENCY SERVICES
Emergency Medical Services
The MCO shall provide that emergency services, including those for specialized behavioral health, be rendered
without the requirement of prior authorization of any kind. The MCO must cover and pay for emergency services
regardless of whether the provider that furnishes the emergency services is part of the MCO’s provider network.
If an emergency medical condition exists, the MCO is obligated to pay for the emergency service.
The MCO shall advise its enrollees of the provisions governing in and out-of-service area use of emergency services
as defined in the Contract.
The MCO shall not deny payment for treatment when a representative of the organization instructs the enrollee
to seek emergency services.
The MCO shall not deny payment for treatment obtained when an enrollee had an emergency medical condition
as defined in 42 C.F.R. § 438.114(a).
The attending emergency physician, or the provider actually treating the enrollee shall determine when the
enrollee is sufficiently stabilized for transfer or discharge and that determination is binding on the MCO for
coverage and payment of emergency and post-stabilization services.
The MCO shall be responsible for educating enrollees and providers regarding appropriate utilization of ED
services, including behavioral health emergencies.
The MCO shall monitor emergency services utilization by enrollees (by provider) and address inappropriate
emergency department utilization.
An enrollee who has an emergency medical condition may not be held liable for payment of subsequent screening
and treatment needed to diagnose the specific condition or stabilize the patient.
Post-Stabilization Services
As specified in 42 C.F.R. § 438.114(e) and 42 C.F.R. § 422.113(c)(2)(i), (ii) and (iii), the MCO must cover and pay for
post-stabilization care services obtained within or outside the MCO’s network that are:
Pre-approved by a network provider or other MCO representative; or
Not preapproved by a network provider or other MCO representative, but:
o Administered to maintain the enrollee’s stabilized condition within one hour of a request to the
MCO for pre-approval of further post-stabilization care services or
o Administered to maintain, improve or resolve the enrollee’s stabilized condition if the MCO:
Does not respond to a request for pre-approval within one hour;
Cannot be contacted; or
The MCO’s representative and the treating physician cannot reach an agreement concerning the
enrollee's care and a network physician is not available for consultation. In this situation, the MCO must
give the treating physician the opportunity to consult with a network physician and the treating physician
MCO Manual | SERVICES | Hospital Services 51
may continue with care of the patient until a network physician is reached or one of the criteria of
(422.133(c)(3)) is met.
The MCO’s financial responsibility for post-stabilization care services that it has not pre-approved ends when:
A network physician with privileges at the treating hospital assumes responsibility for the enrollee’s care;
A network physician assumes responsibility for the enrollee’s care through transfer;
A representative of the MCO and the treating physician reach an agreement concerning the enrollee’s
care; or
The enrollee is discharged.
Emergency Ancillary Services Provided at the Hospital
Emergency ancillary services which are provided in a hospital include, but are not limited to, radiology, laboratory,
emergency medicine and anesthesiology. The MCO shall reimburse the professional component of these services
at a rate equal to or greater than the published Medicaid FFS rate in effect on the date of service to in-network
providers when an MCO authorizes these services (either in-patient or outpatient). Emergency ancillary services
rendered by non-network providers in a hospital setting shall be reimbursed at the published Medicaid fee
schedule in effect on the date of service.
HOSPITAL SERVICES
A hospital is defined as any institution, place, building, or agency, public or private, whether for profit or not,
maintaining and operating facilities, 24-hours a day, seven days a week, having 10 licensed beds or more. The
hospital must be properly staffed and equipped for the diagnosis, treatment and care of persons admitted for
overnight stay or longer who are suffering from illness, injury, infirmity, or deformity or other physical or mental
conditions for which medical, surgical, and/or obstetrical services would be available and appropriate.
An inpatient or outpatient hospital may be the service location for many of the services that are described within
the Services section of this Manual. Unless otherwise detailed within the Hospital Services subsection, the MCO
shall refer to the guidelines and requirements for those specific services as provided within this Manual.
The MCO must ensure that hospitals participating in its network meet all applicable certification and licensing
requirements issued by the state in which they are located. The LDH Health Standards Section (HSS) is the only
licensing authority for hospitals in the state of Louisiana.
As described in the Contract, the MCO’s rate of reimbursement shall be no less than the published Medicaid FFS
rate in effect on the date of service or that is contained on the weekly procedure file sent to the MCO by the fiscal
intermediary, or its equivalent, unless mutually agreed to by both the MCO and the provider in the provider
agreement. The MCO shall also make directed payments to qualified hospitals in accordance with the Contract,
rule, and the State Directed Payment Program Manual.
MCO Manual | SERVICES | Hospital Services 52
General Policies
Inpatient vs. Outpatient Services
The MCO must ensure that inpatient services are not reimbursed as outpatient, even if the stay is less
than 24 hours. Federal regulations are specific in regard to the definition of both inpatient and outpatient
services.
Outpatient services (including diagnostic testing) that are related to an inpatient admission and are
performed either during or within 24 hours of the inpatient admission, regardless of hospital ownership,
will not be reimbursed separately as an outpatient service. The inpatient hospital is responsible for
reimbursing the hospital providing the outpatient services. The inpatient hospital may reflect the
outpatient charges on its claim.
o The only exceptions to this criteria are as follows:
Outpatient therapy services performed within 24 hours before an inpatient admission or
24 hours after the enrollee’s discharge that are either related or unrelated to the inpatient
stay; and
Transfers from a hospital emergency department to a different hospital/provider for
inpatient admission.
o If either of the above exceptions are met, the MCO shall allow separate billing and payment for
the outpatient hospital service.
If an enrollee is treated in the emergency room and requires surgery, which cannot be performed for
several hours because arrangements need to be made, the services may be billed as outpatient provided
the enrollee is not admitted as an inpatient.
Physicians responsible for an enrollee’s care at the hospital are responsible for deciding whether the
enrollee is to be admitted as an inpatient. Physicians should use a 24-hour period as a benchmark, i.e.,
they should order admission for enrollees who are expected to need hospital care for 24 hours or more,
and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex
medical judgment, which can be made only after the physician has considered a number of factors.
Admissions of particular enrollees are not covered or non-covered solely on the basis of the length of time
the enrollee actually spends in the hospital.
The MCO will reimburse up to 48 hours when medically necessary for an enrollee to be in an outpatient
status. This time frame is for the physician to observe the enrollee and to determine the need for further
treatment, admission to an inpatient status or for discharge. If the enrollee is admitted as an inpatient,
the admit date will go back to the beginning of the outpatient services.
Discharge Clarification
The MCO shall consider an inpatient or outpatient to be discharged from the hospital and paid under the
prospective payment system (PPS) when:
The enrollee is formally discharged from the hospital; or
The enrollee dies in the hospital.
MCO Manual | SERVICES | Hospital Services 53
Non-medically necessary circumstances are not considered in determining the discharge time; therefore, the MCO
shall not reimburse hospitals under these circumstances (e.g., enrollee does not have a ride home, does not want
to leave, etc.).
If non-medical circumstances arise and cause the enrollee to stay in the hospital after he/she is discharged, and
the hospital is not reimbursed for the post-discharge portion of the stay, the enrollee may be billed but only after
hospital personnel have informed him/her that Medicaid will not cover that portion of the stay.
If the enrollee is readmitted to a different hospital than the discharging hospital on the same day as discharge,
the readmitting hospital must enter the name of the discharging hospital, as well as the discharge date, in the
appropriate field on the UB-04 claim form.
NOTE: Hospitalized beneficiaries are covered by the type coverage in effect at the time of admission, either FFS or MCO, until
discharge. For example, if a FFS beneficiary is hospitalized on December 31 at 12:00 am but is enrolled in an MCO effective
January 1, the hospitalization is covered by FFS.
Hospital Services Furnished Under Arrangements
Hospitals are allowed by Medicaid to contract or make arrangements with an outside supplier, including another
provider such as an independent laboratory, for performance of medically necessary services for their patients. It
is the responsibility of the hospital to ensure that the outside supplier or other provider meets all applicable state
and federal requirements.
When a hospital contracts with an outside supplier or another provider for the performance of a routine service
or ancillary provider component (technical component of a service), the supplier/provider bills the hospital and is
paid by the hospital. Only the hospital is allowed to submit claims to the MCO for services furnished under this
arrangement. The services are covered hospital services and reimbursement is included in the hospital
reimbursement rates. The MCO may not separately reimburse the outside supplier for services performed on
enrollees who are hospital patients. This policy applies to both inpatient and outpatient hospital services.
Trade Area
Acute care out-of-state providers in the trade area are treated the same as in-state providers. Trade area is defined
as the counties located in Mississippi, Arkansas, and Texas that border the state of Louisiana.
The following is a list of counties located in the trade area:
Louisiana Trade Area
Arkansas Counties
Mississippi Counties
Texas Counties
Chicot County Hancock County Cass County
Ashley County Pearl River County Marion County
Union County Marion County Harrison County
Columbia County Walthall County Panola County
MCO Manual | SERVICES | Hospital Services 54
Louisiana Trade Area
Arkansas Counties
Mississippi Counties
Texas Counties
Lafayette County Pike County Shelby County
Miller County Amite County Sabine County
Wilkerson County Newton County
Adams County Orange County
Jefferson County Jefferson County
Claiborne County
Washington County
Issaquena County
Warren County
A referral or transfer made by a trade area hospital to another hospital does not constitute approval unless it is
to either a Louisiana hospital or another trade area hospital. Prior authorization is required for all other non-
emergency referrals or transfers.
Inpatient Hospital Services
Inpatient hospital care is defined as care needed for the treatment of an illness or injury which can only be
provided safely and adequately in a hospital setting and includes those basic services that a hospital is expected
to provide. The MCO shall not reimburse for care that can be provided in the home or for which the primary
purpose is of a custodial or cosmetic nature.
The following requirements are applicable to hospital inpatient services. The MCO must ensure that its policies
are in alignment with the requirements described below:
Inpatient hospital services must be ordered by the following:
o Attending physician, or other licensed and qualified health care provider;
o An emergency room physician; or
o Dentist (if the patient has an existing condition which must be monitored during the performance
of the authorized dental procedure).
Each day of an inpatient stay must be medically necessary.
Physicians responsible for an enrollee’s care at the hospital are responsible for deciding whether the
enrollee should be admitted as an inpatient. Place of treatment must be based on medical necessity.
The MCO shall require prior authorization for out-of-state non-emergency hospitalization, unless the
request for hospitalization is for a dual Medicare/Medicaid eligible enrollee. Additional service
authorization requirements and exclusions are defined in the Contract.
MCO Manual | SERVICES | Hospital Services 55
Abortions
For detailed requirements around abortions, see the corresponding section in the Professional Services section of
this Manual.
Hospital claims associated with an induced abortion, and those of the attending physician, hospital, assistant
surgeon, and anesthesiologist, as applicable, shall be accompanied by a copy of the attending physician’s written
certification of medical necessity or the Certification of Informed Consent--Abortion form. Therefore, the MCO
shall require providers to submit only hard-copy claims for payment consideration.
All claim forms and attachments shall be retained by the MCO. The MCO shall forward a copy of the claim and its
accompanying documentation to LDH if requested.
Boarder Baby Per Diem
Babies that are not medically appropriate for discharge and remain hospitalized in the regular nursery after the
mother’s discharge are referred to as “boarder babies”. In these cases, the nursery per diem identified on the
Louisiana Medicaid Inpatient Hospital Per Diem Fee Schedule shall be the minimum rate paid to hospitals billing
the appropriate and covered nursery revenue codes.
Covered and Non-Covered Inpatient Hospital Days
The MCO shall require hospitals to bill covered days and their associated ancillary charges. Covered days are days
that have been approved through the precertification process.
The MCO may permit hospitals to bill non-covered days and their associated ancillary charges but these must be
billed separately from covered days and their associated ancillary charges. Non-covered days are days that are
not certified or approved by the MCO. Even though these non-covered days and services will be denied by the
MCO, the MCO must submit a denied encounter for these claims if billed by the provider.
When the MCO receives an inpatient claim (electronic or paper) that includes dates of service that exceed
approved days, the MCO must deny the entire claim. The provider must resubmit the inpatient claim for covered
days only.
For example: If a provider obtains approval for a 10-day stay and submits a claim for 12 days, the claim must be
denied and resubmitted for the 10 approved days only.
Patient Day Recording
The MCO shall count the number of days of care charged to an enrollee for inpatient hospital services in units of
full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in
counting days of care for Medicaid reporting purposes. A part of a day, including the day of admission, counts as
a full day. However, the day of discharge or death is not counted as a day unless discharge or death occurs on the
day of admission. If admission and discharge or death occur on the same day, the day is considered a day of
admission and counts as one inpatient day.
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837I Billing Instructions
Service Line Items (SV203) – Line Item Charge Amount is the total charge amount for the Service-Line; it includes
covered charges and non-covered charges (applicable for covered days only).
For accommodation service line items, the number of covered accommodation service days value (quantity) shall
be sent in SV205 along with SV204 set to “DA” (days).
If the provider identifies service line items with non-covered charges or line item charges that are denied by the
MCO, the non-covered charges must be identified and reported in the SV207 on the encounter.
The CLM02 (Total Claim Charge Amount) value shall equal the sum of all of the SV203 (Line Item Charge Amount)
values. Since the SV203 value includes both covered and non-covered charges, CLM02 also includes both.
HI*BE:80 – Covered Service Days (value in whole numbers only).
Deliveries Prior to 39 Weeks
The MCO shall not cover induced deliveries prior to 39 weeks gestation unless it is medically necessary to induce
labor prior to 39 weeks gestation. MCOs must have processes in place to validate that the delivery was not induced
prior to 39 weeks or if prior to 39 weeks, that it was medically necessary.
Deliveries with Non-Reimbursable Sterilizations
The MCO shall cover an inpatient hospital claim for a delivery/cesarean section even when a non-reimbursable
sterilization is performed during the same hospital stay.
When there is no valid sterilization form obtained, the procedure code for the sterilization and the diagnosis code
associated with the sterilization must not be reported on the claim form, and charges related to the sterilization
process must not be included on the claim form. Providers will continue to receive their per diem for covered
charges for these services.
NOTE: A sterilization procedure is considered non-reimbursable if the sterilization consent form is either missing or invalid.
Distinct Part Psychiatric Units
Medicaid recognizes distinct part psychiatric units within an acute care general hospital differently for
reimbursement purposes if the unit meets Medicare’s criteria for exclusion from Medicare’s Prospective Payment
System (PPS excluded unit). The unit must have the LDH HSS verify that the Unit is in compliance with the PPS
criteria and identify the number and location of beds in the psychiatric unit.
Hospital-Based Ambulance Services (Inpatient — Air and Ground)
If a hospital admits an inpatient that is transported by its own hospital-based ambulance (ground or air), the MCO
shall cover the ambulance charges, which must be billed as part of inpatient hospital services.
It may be necessary to transport an inpatient temporarily to another hospital for specialized care while the
enrollee maintains inpatient status. These services are not billable ambulance services.
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If a hospital-based ambulance transports an enrollee for inpatient admission to any other hospital, the ambulance
service is not part of the hospital service and may be covered under the independent ambulance provider number.
Hospital-based ambulances must meet equipment and personnel standards set by the Bureau of Emergency
Services (EMS). Hospitals must submit a copy of the EMS certification to Provider Enrollment for recognition to
bill ambulance services.
Hysterectomies
For detailed requirements around coverage of hysterectomies, please see the corresponding section of the
Professional Services section of this Manual.
Prior to providing payment to the provider performing the hysterectomy, the MCO shall ensure that the
hysterectomy consent form or a physician’s written certification is obtained. The MCO shall allow ancillary
providers and hospitals to submit claims without the hard copy consent. The MCO shall reimburse these providers
only if the provider performing the hysterectomy submitted a valid hysterectomy consent form and was
reimbursed for the procedure.
The MCO shall retain all required documentation.
Intensive Care Units
Neonatal Intensive Care Units
Reimbursement methodology recognizes four categories of neonatal units based on the certification of a hospital
to provide neonatal intensive care services at a minimum standard for each category of Neonatal Intensive Care
Units (NICUs): NICU I, NICU II, NICU III, and NICU III Regional.
Pediatric Intensive Care Units
Reimbursement methodology recognizes two categories of Pediatric Intensive Care Units (PICUs) based on the
certification of a hospital to provide pediatric intensive care services at a minimum standard for each category of
PICU: PICU II; and PICU I.
Mother/Newborn/Nursery
The MCO shall cover a hospital stay following a normal vaginal delivery of at least 48 hours for both the mother
and newborn child, and at least 96 hours following a cesarean section delivery for both the mother and newborn
child. All medically necessary services are the responsibility of the MCO regardless of primary or secondary mental
health diagnosis.
The MCO may require notification by the provider of obstetrical admissions exceeding 48 hours after vaginal
delivery. The MCO is allowed to deny a portion of a claim for payment based solely on lack of notification by the
provider of obstetrical admission exceeding 48 hours after vaginal delivery. In this case, the MCO may only deny
the portion of the claim related to the inpatient stay beyond 48 hours.
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The MCO may require notification by the provider of obstetrical admissions exceeding 96 hours after Caesarean
section. The MCO is allowed to deny a portion of a claim for payment based solely on lack of notification by the
provider of obstetrical admission exceeding ninety-six (96) hours after Caesarean section. In this case, the MCO
may only deny the portion of the claim related to the inpatient stay beyond 96 hours.
The MCO shall require providers to bill mother and newborn claims separately. The claim is to include only the
mother’s room/board and ancillary charges. A separate claim for the newborn must include only nursery and
ancillary charges for the baby. This newborn claim shall be paid at zero as opposed to being denied in order to be
counted as a covered service in encounter data.
When a newborn remains hospitalized after the mother’s discharge, the claim must be split billed. The first billing
of the newborn claim must be for charges incurred on the dates that the mother was hospitalized. The second
billing must be for the days after the mother’s discharge. The newborn assumes the mother’s discharge date as
his or her admit date.
Outliers
In compliance with the requirement of Section 1902(s)(1) of the Social Security Act, additional payment shall be
made for catastrophic costs associated with services provided to:
Children under age six who received inpatient services in a disproportionate share hospital setting, and
Infants who have not attained the age of one year who received inpatient services in any acute care
setting.
Outlier payments are not payable for transplant procedures and services provided to enrollees with Medicaid
coverage that is secondary to other payer sources.
Outlier payments are calculated based on each hospital’s eligible outlier claims for discharges during the state
fiscal year. Payment per hospital is limited to their pro rata share of the annual catastrophic outlier pool amount
as established by rule and approved Louisiana Medicaid State Plan. Claims qualifying for payment from the outlier
pool must meet the following conditions:
The claims must be for children less than six years of age who received inpatient services in a
disproportionate share hospital setting; or infants less than one year of age who receive inpatient services
in any acute care hospital setting; and
The costs of the case must exceed $150,000. The hospital specific cost-to-charge ratio utilized to calculate
the claim costs shall be calculated using the Medicaid NICU or PICU costs and charge data from the most
current cost report.
Out-of-State Acute Care Hospitals
Psychiatric and Substance Abuse
The MCO shall cover inpatient psychiatric or substance abuse treatment in out-of-state hospitals for a maximum
of two days in the case of a medical emergency.
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Out-of-State Inpatient Psychiatric Services
The MCO shall cover inpatient stays for psychiatric or substance abuse treatment in out-of-state hospitals only in
the event of a medical emergency for a maximum of two days to allow time for the enrollee to be stabilized and
transferred to a Louisiana psychiatric hospital when appropriate. The MCO shall not cover outpatient psychiatric
and substance abuse services provided by an out-of-state hospital.
Psychiatric Diagnosis within an Acute Care Hospital
When the enrollee’s primary diagnosis is psychiatric, reimbursement will be on the psychiatric per diem and not
the long-term or acute care rate.
Psychiatric Hospitals (Free-Standing and Distinct Part)
Reimbursement for services provided in these facilities is a prospective per diem rate. This per diem includes all
services provided to inpatients, except for physician services, which must be billed separately. All therapies
(individual/group counseling or occupational therapy) must be included in the per diem. Federal regulations
prohibit Medicaid reimbursement for enrollees ages 22-64 in a free-standing psychiatric hospital setting except
as an LDH-approved in-lieu-of service.
Rapid Whole Genome Sequencing of Critically Ill Infants
The MCO shall cover rapid whole genome sequencing performed in the inpatient setting for infants with complex
illnesses of unknown etiology. Rapid whole genome sequencing includes: individual sequencing; trio sequencing
of the parents of the infant; and ultra-rapid sequencing.
Eligibility Criteria
Rapid whole genome sequencing is considered medically necessary for infants less than 12 months of age who
are receiving inpatient hospital services in an intensive care or pediatric unit if they meet the following criteria:
Are suspected of having a rare genetic condition that is not diagnosable by standard methods;
Have symptoms that suggest a broad differential diagnosis that requires an evaluation by multiple genetic
tests if advanced molecular techniques, including, but not limited to, traditional whole genome
sequencing, rapid whole genome sequencing, and other genetic and genomic screening, are not
performed;
Timely identification of a molecular diagnosis is necessary to guide clinical decision making, and the
advanced molecular techniques including, but not limited to, traditional whole genome sequencing, rapid
whole genome sequencing, and other genetic and genomic screening results may guide the treatment or
management of the infant's condition;
Have an illness with at least one of the following features:
o Multiple congenital anomalies;
o Specific malformations highly suggestive of a genetic etiology;
o Abnormal laboratory tests suggesting the presence of a genetic disease or complex metabolic
phenotype like, but not limited to, an abnormal newborn screen, hyperammonemia, or lactic
acidosis not due to poor perfusion;
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o Refractory or severe hypoglycemia;
o Abnormal response to therapy related to an underlying medical condition affecting vital organs
or bodily systems;
o Severe hypotonia;
o Refractory seizures;
o A high-risk stratification on evaluation for a brief resolved unexplained event with any of the
following:
A recurrent event without respiratory infection,
A recurrent witnessed seizure-like event, or
A recurrent cardiopulmonary resuscitation;
o Abnormal chemistry levels including, but not limited to, electrolytes, bicarbonate, lactic acid,
venous blood gas, and glucose suggestive of inborn error of metabolism;
o Abnormal cardiac diagnostic testing results suggestive of possible channelopathies, arrhythmias,
cardiomyopathies, myocarditis, or structural heart disease; or
o Family genetic history related to the infant's condition.
Prior Authorization
Rapid whole genome sequencing requires prior authorization and must be ordered by the infant’s treating
physician. The ordering physician must be a medical geneticist or other physician sub-specialist including, but not
limited to, a neonatologist or pediatric intensivist with expertise in the conditions and/or genetic disorder for
which testing is being considered. Counseling is required before and after all genetic testing, and must be
documented in the medical record, as per the Genetic Counseling and Testing section of this Manual.
Reimbursement
The MCO shall reimburse rapid whole genome testing separately from the hospital reimbursement for inpatient
services. The minimum reimbursement for rapid whole genome sequencing (including reimbursement for
individual sequencing, trio sequencing of the parents of the infant, and ultra-rapid sequencing) is equal to the fees
on the Louisiana Medicaid Laboratory and Radiology (Non-Hospital) Fee Schedule in addition to the minimum per
diem as published in the Louisiana Medicaid Inpatient Hospital Per Diem Fee Schedule.
Hospitals must bill the rapid whole genome sequencing claim using the appropriate CPT code on a CMS 1500 claim
form. If the hospital bills electronically, the 837P must be used.
Rehabilitation Units in Acute Care Hospitals
Rehabilitation Units (Medicare designated) are considered part of the acute care hospital, and services are to be
billed with the acute care provider number. Reimbursement rates are the same as for the acute care hospital.
Separate Medicaid provider numbers are not issued for rehabilitation units.
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Services Reimbursed Separately from Per Diem Rate
Hospitals are to be reimbursed on an all-inclusive per diem for services provided. The MCO is required to
reimburse hospitals the minimum per diem as published on the Medicaid FFS fee schedule. However, the following
services, if provided in an inpatient setting, are to be reimbursed in addition to the minimum per diem:
Cochlear devices
Donor human milk
Intraocular lens implants*
Intrathecal baclofen therapy infusion pumps
Long acting reversible contraceptives
Newborn screening panels performed in acute care hospital settings
Vagus nerve stimulator devices*
*Refer to the Outpatient Hospital Services section for additional detail about these services.
Cochlear Implants
For detailed requirements around coverage of cochlear implants, see the corresponding section of the
Professional Services section.
When the implantation procedure is performed in the hospital setting, the MCO shall reimburse the hospital for
the device(s) in addition to the hospital payment.
Donor Human Milk
The MCO shall cover donor human milk provided in the inpatient hospital setting for certain medically vulnerable
infants. This coverage shall be provided without restrictions or the requirement for prior authorization. Donor
human milk is considered medically necessary when all of the following criteria are met:
The hospitalized infant is less than 12 months of age with one or more of the following conditions:
o Prematurity;
o Malabsorption syndrome;
o Feeding intolerance;
o Immunologic deficiency;
o Congenital heart disease or other congenital anomalies;
o Other congenital or acquired condition that places the infant at high risk of developing necrotizing
enterocolitis (NEC) and/or infection; and
The infant’s caregiver is medically or physically unable to produce breast milk at all or in sufficient
quantities, is unable to participate in breastfeeding despite optimal lactation support, or has a
contraindication to breastfeeding; and
The infant’s caregiver has received education on donor human milk, including the risks and benefits, and
agrees to the provision of donor human milk to their infant; and
The donor human milk is obtained from a milk bank accredited by, and in good standing with, the Human
Milk Banking Association of North America.
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Reimbursement
The MCO shall reimburse donor human milk separately from the hospital reimbursement for inpatient services.
The minimum reimbursement for the donor human milk is the fee on file on the Louisiana Medicaid Durable
Medical Equipment (DME) Fee Schedules.
Hospitals must bill the donor human milk claim using the Healthcare Common Procedure Coding System (HCPCS)
procedure code T2101 (1 unit per ounce) on a CMS 1500 claim form.
Intrathecal Baclofen Therapy
For detailed requirements around coverage of intrathecal baclofen therapy, see the corresponding section in the
Professional Services section of this Manual.
When the implantation procedure is performed in the hospital setting, the MCO shall reimburse the hospital for
the pump in addition to the hospital reimbursement.
Long-Acting Reversible Contraceptives in the Inpatient Hospital Setting
The MCO shall cover long-acting reversible contraceptive (LARC) devices, in addition to the hospital
reimbursement, when provided in the postpartum period prior to discharge. Minimum reimbursement for the
LARC device is provided on the Louisiana Medicaid Durable Medical Equipment (DME) Fee Schedules. Hospitals
shall bill the claim for the LARC, separate from the inpatient stay, on the CMS 1500 claim form.
Specialty Units
Certain resource intensive inpatient services are recognized through a separate reimbursement methodology by
Louisiana Medicaid. The MCO shall refer to the corresponding rate applicable to the type and level of service in
the Medicaid FFS fee schedule for the minimum per diems established for the following inpatient services:
neonatal intensive care units, pediatric intensive care units, and burn units.
Split-Billing
The MCO must require split-billing in the following circumstances:
Hospitals must split-bill claims at the hospital’s fiscal year end;
Hospitals must split-bill claims when the hospital changes ownership;
Hospitals must split-bill claims if the charges exceed $999,999.99; and
Hospitals must split-bill claims with more than one revenue code that utilizes specialized per diem pricing
(e.g., PICU, NICU).
The MCO may grant hospitals the discretion to split-bill claims as warranted by other situations that may arise.
Split-Billing Procedures
The MCO shall provide the following instructions for split-billing on the UB-04 claim form.
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In the Type of Bill block (form locator 4), the hospital must enter code 112, 113 or 114 to indicate the specific type
of facility, the bill classification, and the frequency for both the first part and the split-billing interim and any
subsequent part of the split-billing interim.
In the Patient Status block (form locator 17), the hospital must enter a 30 to show that the enrollee is "still a
patient."
NOTE: When split-billing, the hospital must not code the first claim as a discharge.
In the Remarks section of the claim form, the hospital must write in the part of stay for which it is split-billing. For
example, the hospital must write in "Split-billing for Part 1," if it is billing for Part 1.
Providers submitting a hospital claim which crosses the date for the fiscal year end, must complete the claim in
two parts: (1) through the date of the fiscal year end and (2) for the first day of the new fiscal year.
Sterilizations
For detailed requirements around coverage of sterilizations, see the corresponding section of the Professional
Services section of this Manual.
Prior to providing reimbursement to the provider performing the sterilization, the MCO shall ensure that the
sterilization consent form is obtained. The physician who signs the consent form must be the physician listed as
the attending physician on the UB-04.
The MCO shall allow ancillary providers and hospitals to submit claims without the hard copy consent. The MCO
shall reimburse these providers only if the provider performing the sterilization submitted a valid sterilization
consent and was reimbursed for the procedure.
The MCO shall retain all required documentation.
NOTE: Refer to Deliveries with Non-Reimbursable Sterilizations for deliveries when a non-reimbursable sterilization is
performed during the same hospital stay.
Surgeries Performed on an Inpatient Basis
The MCO shall cover certain surgical procedures only when performed as outpatient unless it is medically
necessary for the procedure to be performed on an inpatient basis. These procedures are usually performed on
an outpatient basis but can be performed inpatient if it is medically necessary. A list of outpatient procedures
requiring approval to be performed on an inpatient basis may be found on the Medicaid FFS fee schedules.
The MCO may approve inpatient performance of these procedures when one or more of the following exception
criteria exists:
Documented medical conditions exist that make prolonged pre-and/or post-operative observation by a
nurse or skilled medical personnel a necessity.
The procedure is likely to be time consuming or followed by complications.
An unrelated procedure is being performed simultaneously that requires hospitalization.
There is a lack of availability of proper post-operative care.
Another major surgical procedure could likely follow the initial procedure (e.g., mastectomy).
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Technical difficulties, as documented by admission or operative notes, could exist.
The procedure carries high enrollee risk.
Reimbursement for the performance of these specified surgical procedures on an outpatient basis will be made
on a flat fee-for-service basis. Reimbursement for surgical procedures approved for an inpatient performance will
be made in accordance with the prospective reimbursement methodology for acute care inpatient hospital
services.
Transplant Services
In-state transplant services are reimbursed at costs subject to a hospital-specific per diem limit that is based on
each hospital’s actual cost in the base year established for each type of approved transplant. Out-of-state
transplant services are reimbursed at 40 percent of billed charges for adults age twenty-one and older and 60
percent of billed charges for children through age twenty.
Well-Baby Per Diem
Private hospitals that perform more than 1,500 Louisiana Medicaid deliveries per state fiscal year (SFY) qualify to
be paid a per diem for well babies that are discharged at the same time the mother is discharged.
Outpatient Hospital Services
Outpatient hospital services are defined as diagnostic and therapeutic services rendered under the direction of a
physician or dentist to an outpatient in an enrolled, licensed and certified hospital. The MCO shall cover medically
necessary outpatient hospital services provided to enrollees.
Common Observation Policy
The MCO shall utilize the following common observation policy, which has been developed collectively by MCO
personnel with LDH approval. This policy shall be reviewed annually by LDH and the MCOs in its entirety. Any
revisions shall be reviewed and approved by LDH at least 30 calendar days prior to implementation of any new or
revised language. The purpose of the outpatient hospital services program is to provide outpatient services to
eligible Medicaid enrollees performed on an outpatient basis in a hospital setting. Hospitals are to ensure that the
services provided to Medicaid enrollees are medically necessary, appropriate and within the scope of current
evidence-based medical practice and Medicaid guidelines.
Observation Time: The period beginning at the time the order is written to place an enrollee in
observation status or the time an enrollee presents to the hospital with an order for
observation, and ending with discharge of the enrollee, or an order for inpatient admission.
Observation Care: A well-defined set of specific, clinically appropriate services furnished while
determining whether an enrollee will require formal inpatient admission or be discharged from
the hospital. Observation is for a minimum of one hour and up to 48 hours.
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*The enrollee must be in the care of a physician during the period of observation, as
documented in the medical record by an observation order, discharge, and other appropriate
progress notes that are timed, written, and signed by the physician.
Observation Procedure
The MCO shall reimburse up to 48 hours of medically necessary care for an enrollee to be in an observational
status. This time frame is for the physician to observe the enrollee and to determine the need for further
treatment, admission to an inpatient status, or for discharge. Observation and ancillary services do not require
notification, precertification or authorization and will be covered up to 48 hours.
Hospitals should bill the entire outpatient encounter, including emergency department, observation and any
associated services on the same claim with the appropriate revenue codes, and all covered services are to be
processed and paid separately.
Any observation service over 48 hours requires MCO authorization. For observation services beyond 48 hours that
are not authorized, the MCO shall only deny the non-covered hours.
If an enrollee is anticipated to be in observation status beyond 48 hours, the hospital must notify the MCO as soon
as reasonably possible for potential authorization of an extension of hours. The MCO and provider shall work
together to coordinate the provision of additional medical services prior to discharge of the enrollee as needed.
Observation-to-Inpatient Procedure
Length of stay alone should not be the determining factor in plan denial of inpatient stay/downgrading to
observation stay.
Medicaid enrollees should not be automatically converted to inpatient status at the end of the 48 hours.
Admission of an enrollee cannot be denied solely on the basis of the length of time the enrollee actually spends
in the hospital.
All hospital facility charges on hospital day one are included in the inpatient stay and billed accordingly inclusive
of emergency department/observation facility charges. (Note: Professional charges should continue to be billed
separately.)
All observation status conversions to an inpatient hospital admission require notification to the MCO within one
business day of the order to admit an enrollee. Acceptable notifications include the use of MCO provider portals,
admit discharge transfer notifications, and other mediums through which MCOs accept clinical communications.
MCOs are prohibited from including any observation hours in the inpatient admission notification period.
The MCO will notify the provider rendering the service, whether a healthcare professional or facility or both,
verbally or as expeditiously as the enrollee’s health condition requires but within no more than one business day
of making the initial determination. The MCO will subsequently provide written notification (i.e., via fax) to the
provider within two business days of making the decision to approve or deny an authorization request.
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Observation Charges
The MCO must require hospitals to bill for observation services following the common observation policy.
Observation services must be billed using revenue code 762 and the appropriate accompanying HCPCS code(s) of
G0378 and/or G0379.
MCOs may not reimburse for outpatient surgical procedures provided on the same day as observation.
Diabetes Self-Management Training
For detailed requirements around coverage of diabetes self-management training, see the corresponding
subsection of the Professional Services section of this Manual.
The MCO shall reimburse for DSMT services as a flat fee based on the Louisiana Medicaid Professional Services
Fee Schedule, at a minimum, minus the amount which any third party coverage would pay. The following
Healthcare Common Procedure Coding System (HCPCS) codes or their successors are used to bill DSMT services:
G0108-Diabetes outpatient self-management training services, individual, per 30 minutes
G0109-Diabetes self-management training services, group session (two or more) per 30 minutes
NOTE: Services provided to pregnant women with diabetes must be billed with the “TH” modifier.
Hospitals are to bill the above HCPCS codes in the outpatient setting along with Revenue code 942. These are the
only HCPCS codes currently allowed to be billed with HR942.
Emergency Department Services
The MCO shall cover emergency department services for an emergency medical condition, subject to the “prudent
layperson standard” as required in federal law and regulations. A person with an emergency medical condition
presents with a medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably
expect the absence of medical attention to result in:
Placing the health of the individual, or in the case of a pregnant woman, the health of the woman or her
unborn child, in serious jeopardy;
Serious impairment of bodily function; or
Serious dysfunction of any organ or body part.
Hospitals with emergency departments are required by EMTALA (Emergency Medical Treatment and Labor Act)
to perform a Medical Screening Exam (MSE) on all persons who present to the emergency department for services.
If the MSE does not reveal the existence of an emergency medical condition under the prudent layperson
standard, the enrollee must be advised that Medicaid does not cover routine/non-emergent care provided in the
emergency department when the presenting symptoms do not meet the prudent layperson standard of an
emergency condition and that he or she may receive a bill if they are treated in the emergency department. The
enrollee must be referred to his or her primary care physician (PCP) for follow-up and evaluation.
Federal Medicaid regulations and policy prohibit the use of diagnosis codes (either symptoms or final diagnosis)
for denying claims. The MCO is required to base coverage decisions for emergency services on the apparent
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severity of the symptoms at the time of presentation and to cover examinations when presenting symptoms are
of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson. The
final determination of coverage and reimbursement must be made by taking into account the presenting
symptoms rather than the final diagnosis.
The MCO shall require provider to bill revenue code 450 or 459 when submitting claims for outpatient emergency
department services. Only one revenue code 450 or 459 may be used per emergency department visit. These
revenue codes must be billed with the appropriate accompanying CPT codes of 99281, 99282, 99283, 99284,
99285, 99291 and 99292. Claims for emergency department services are not to be billed as a single line item.
Claims must include all revenue codes (i.e., pharmacy, lab, x-rays and supplies) which were utilized in the
enrollee’s treatment, using the appropriate revenue code and HCPCS when applicable.
When an emergency visit results in an inpatient admit, providers must bill all charges associated with the
emergency visit on the inpatient bill. This policy applies to enrollees admitted from the emergency department or
if the enrollee has been seen in the emergency department within 24 hours either prior to admit or after the
inpatient discharge. The emergency department charges must be billed as a separate line. All associated charges
for the emergency visit must be included by revenue code with the total charges for the inpatient stay.
Hospital-Based Ambulances (Outpatient — Ground only)
The MCO shall cover emergency transports by a hospital’s own hospital-based ambulance (ground only) for
enrollees treated and released as an outpatient. These must be billed as part of outpatient hospital services.
If a hospital-based ambulance transports a patient for emergency outpatient treatment to any other hospital, the
ambulance service is not part of the hospital service and may be covered under the independent ambulance
provider number.
Hospital-based ambulances may be used only to transport enrollees to the hospital in an emergency so they may
be stabilized.
The MCO shall not cover non-emergency transport by a hospital-based ambulance as a hospital service.
NOTE: Air ambulance is not covered as an outpatient service.
Hospital-based ambulances must meet equipment and personnel standards set by the Bureau of Emergency
Medical Services (EMS). Hospitals must submit a copy of EMS certification to Provider Enrollment for recognition
to bill ambulance charges.
Hyperbaric Oxygen Therapy
The MCO shall cover hyperbaric oxygen therapy when provided in an outpatient hospital setting. For detailed
requirements related to hyperbaric oxygen therapy coverage, see the corresponding subsection of the
Professional Services section in this Manual.
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Intraocular Lens Implants
When intraocular lens implantation is performed in the outpatient hospital setting, the MCO shall reimburse for
the intraocular lens implant in addition to the outpatient hospital surgery reimbursement. The MCO shall only
reimburse the provider who actually supplies the lens.
Long-Acting Reversible Contraceptives in the Outpatient Hospital
Setting
The MCO shall make an additional reimbursement to hospitals for long-acting reversible contraceptive (LARC)
devices when they are inserted during an outpatient hospital visit. Reimbursement for the LARC device in the
outpatient hospital setting is in addition to the outpatient hospital reimbursement.
Hospitals shall bill the DME revenue code of 290 with the appropriate accompanying HCPCS code for the LARC
device on the UB-04. The MCO may refer to the Louisiana Medicaid Durable Medical Equipment (DME) Fee
Schedules for covered LARCs and their minimum reimbursement.
NOTE: Refer to the Inpatient Hospital Services section for LARCs in the inpatient hospital setting.
Out-of-State Hospital Outpatient Services
Approved outpatient hospital services will be reimbursed at 31.04 percent of billed charges except for those
outpatient services reimbursed based on a fee schedule. The Medicaid Program does not cost settle out-of-state
hospitals.
Outpatient Hospital Clinic Services
The payable revenue codes are 510, 514, 515, 517, and 519. These revenue codes must be billed with the
appropriate accompanying office setting E&M CPT code.
Outpatient Rehabilitation Services
The MCO shall cover outpatient rehabilitation services, which include:
Physical therapy;
Occupational therapy;
Speech therapy; and
Hearing therapy.
Proton Beam Radiation Therapy
The MCO shall not cover Proton Beam Radiation Therapy (PBRT) for enrollees 21 years of age and older.
Psychiatric and Substance Abuse
The MCO shall not cover outpatient psychiatric or substance abuse treatment in an outpatient hospital setting.
MCO Manual | SERVICES | Laboratory Services 69
Same-Day Outpatient Visits
Enrollees under Age 21
When medically necessary, two same-day outpatient visits per specialty per enrollee are allowed; however, the
second same-day outpatient visit is reimbursable for only the two lowest level evaluation and management (E&M)
codes.
If an Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening has been paid, only the two lowest
level E&M codes are payable for the same enrollee, on the same date of service and by the same attending
provider. In these circumstances, when it is clinically appropriate, providers may use the correct modifier to allow
both services to be covered
A same-day follow-up office visit for the purpose of fitting eyeglasses is allowed, but no higher level office visit
than the lowest level E&M code is payable for the fitting. Appropriate modifier usage may be required.
Enrollees Age 21 and Over
If a preventive medicine E&M service has been paid, only the two lowest level E&M codes are payable for the
same enrollee, on the same date of service, and by the same attending provider.
Screening Mammography
For requirements related to screening mammography coverage, see the corresponding subsection of the
Professional Services section in this Manual.
The MCO shall reimburse hospitals billing with revenue code 403 and the appropriate accompanying CPT codes
for screening mammograms.
Vagus Nerve Stimulators
For detailed requirements around vagus nerve stimulator coverage, please see the corresponding subsection in
the Professional Services section of this Manual.
The MCO shall advise hospitals to confirm that the provider performing the implantation has received an
authorization for the procedure prior to submitting their claim in order to prevent denials. The MCO shall
reimburse for vagus nerve stimulators using HCPCS procedure code C1767 (VNS generator) and/or C1778 (VNS
leads). The MCO shall reimburse following review of the provider’s approved authorization.
LABORATORY SERVICES
The MCO shall cover inpatient and outpatient (hospital and non-hospital) laboratory services when ordered by a
physician or other licensed practitioner acting within their scope of practice. The MCO shall cover laboratory
services that may be required to treat an emergency or to provide surgical services for an excluded service, such
as dental services.
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CLIA Certification
The MCO shall require all providers to include a valid Clinical Laboratory Improvement Amendments (CLIA)
number on all claims submitted for laboratory services, including CLIA waived tests.
The MCO shall apply CLIA claim edits to all claims for laboratory services that require CLIA certification and deny
those claims that do not meet the required criteria.
The MCO shall edit claims to ensure reimbursement is not made to:
Providers who do not have a CLIA certificate;
Providers rendering services outside the effective dates of the CLIA certificate; and
Providers submitting claims for services not covered by their CLIA certificate.
Providers with waiver or provider-performed microscopy (PPM) certificate types may be paid for only those waiver
and/or PPM codes approved for billing by CMS.
NOTE: The CLIA number is not required for UB-04 claims.
In-Office Laboratory Services
The MCO shall cover laboratory services furnished in an office or similar facility other than a hospital outpatient
department or clinic. The MCO must only reimburse physicians and other licensed practitioners for laboratory
services that they personally perform or supervise and must ensure that physicians and other licensed
practitioners comply with all state and federal requirements.
Hospital Laboratory Services
The MCO shall cover laboratory services furnished in a hospital laboratory.
For inpatient laboratory services, the MCO shall allow hospitals to contract with an independent laboratory. The
MCO shall ensure that the hospital pays the laboratory for the technical component. The MCO shall reimburse the
independent laboratory for only the professional component of the service, when applicable.
For outpatient laboratory services, the MCO shall allow hospitals to contract with an independent laboratory.
When a hospital contracts with an independent laboratory for the performance of the technical service only, the
MCO shall require the hospital to pay the laboratory. The MCO shall not reimburse the independent laboratory
for the technical component only.
When a hospital contracts with an independent laboratory for outpatient or inpatient services, the MCO shall
require the hospital to ensure that both the physician who performs the professional service and the laboratory
that performs the technical service meet all applicable state and federal requirements.
Independent Laboratories
The MCO shall cover laboratory services provided in independent laboratories. An independent laboratory
performs diagnostic tests and is independent of the ordering provider, the hospital, or both.
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The MCO shall only contract with independent laboratories that meet all applicable state and federal
requirements.
Providers are limited to billing the laboratory services that they are CLIA-certified to perform.
Specimen Collection
The MCO shall not reimburse separately for specimen collection, as that service is considered incidental to the
evaluation and management service, the laboratory test, or both.
Urine Drug Testing
The MCO shall cover presumptive and definitive urine drug testing under the following parameters:
Presumptive drug testing is limited to 24 total tests per enrollee per calendar year.
Definitive drug testing is limited to 12 total tests per enrollee per calendar year. Definitive drug testing is
limited to individuals with an unexpected positive or unexpected negative finding on presumptive drug
testing or if there is a clinical reason to detect a specific substance or metabolite that would be
inadequately detected through presumptive drug testing.
Testing more than 14 definitive drug classes in one test is not reimbursable.
No more than one presumptive test and one definitive test shall be reimbursed per day per enrollee, from
the same or different provider.
Universal drug testing (screening) in a primary care setting is not covered. Drug testing without signs or
symptoms of substance use or without current controlled substance treatment is not covered.
MEDICAL TRANSPORTATION
The MCO is required to provide emergency and non-emergency medical transportation for its enrollees. Coverage
information by enrollment type is provided in the following matrix:
Enrollment
Non-Ambulance
Non-Emergency
Ambulance
Emergency Ambulance
Managed care for physical
and behavioral health
MCO
MCO
MCO
Managed care for physical
health only (CSoC children)
MCO
MCO
MCO
Managed care for
behavioral health only
MCO
MCO
Medicaid FFS
Nursing home residents
Included in facility per
diem
MCO
MCO for month of
admission*;
Medicaid FFS for
subsequent months
Children in ICF-IIDs
†
Included in facility per
diem
MCO
Medicaid FFS
Adults in ICF-IIDs
†
Included in facility per
diem
Medicaid FFS^
Medicaid FFS
MCO Manual | SERVICES | Medical Transportation 72
Excluded populations
Medicaid FFS^
Medicaid FFS^
Medicaid FFS
† Intermediate Care Facility for Individuals with Intellectual Disabilities
^ Verida (formerly Southeastrans) is currently approving and reimbursing for these transportation services covered by
Medicaid FFS.
*During the single transitional month where an enrollee is both in a P-linkage and certified in LTC, the MCO will remain
responsible for all transportation services that are not the responsibility of the nursing facility.
The MCO may elect to contract with a transportation broker but shall maintain ultimate responsibility for adhering
to and otherwise fully complying with the policies, instructions, and guidelines herein, any applicable Contract
provisions, and any applicable state and federal requirements.
Non-Emergency Medical Transportation
Non-emergency medical transportation (NEMT) is transportation provided to Medicaid enrollees to and/or from
a Medicaid covered service, including carved-out services, or value-added benefit (VAB) when no other means of
transportation is available. NEMT does not include transportation provided on an emergency basis, such as trips
to emergency departments in life threatening situations.
This section is applicable to non-ambulance, non-emergency medical transportation only. See the Ambulance
section of this Manual for guidelines specific to non-emergency ambulance transportation (NEAT). NEMT shall not
include any non-emergency ambulance transportation or other type of transportation by ambulance. See La. R.S.
40:1257.1. Services shall be provided in accordance with the Louisiana Administrative Code, Title 50, Part XXVII,
Chapter 5.
Covered Services
The MCO shall cover NEMT for the least costly means of transportation available that accommodates the level of
service required by the enrollee to and/or from a Medicaid covered service.
NEMT must be within the enrollee’s transportation service area. The transportation service area is defined as the
area that complies with the geographic access standards outlined in Contract Attachment F, Provider Network
Standards.
Eligible expenses include the following when necessary to ensure the delivery of medically necessary services:
Transportation for the enrollee and one attendant; and
Meals, lodging, and other related travel expenses for the enrollee and one attendant when long distance
travel is required. Long distance is defined as when the total travel time, including the duration of the
appointment plus the travel to and from the appointment, exceeds 12 hours.
o The MCO must establish a reimbursement policy that does not exceed per diem rates established
by the U.S. General Services Administration [link
].
o The MCO must allow for meals and lodging, for each trip that are not otherwise covered in the
inpatient per diem, primary insurance, or other payer source.
o If the MCO denies meals and lodging services to an enrollee who requests these services, the
member must receive a written notice of denial explaining the reason for denial and the member’s
right to an appeal.
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Scheduled trips in which no transportation of the enrollee occurs are not billable.
Reimbursement to transportation providers shall be no less than the published Medicaid FFS rate in effect on the
date of service, unless mutually agreed to by the MCO and the transportation provider in the provider agreement.
Exceptions to Standards
The transportation service area applies for P-linkage enrollees who are enrolled in an MCO for physical health,
behavioral health, and transportation services. It is not applicable to B-linkage enrollees who are enrolled in an
MCO for specialized behavioral health and NEMT services.
If a P-linkage enrollee does not have a choice of at least two medical providers within the geographic access
standards, the transportation service area may be extended to the nearest medical provider beyond the
geographic access standards. If the enrollee does have a choice of at least two medical providers within the
transportation service area but chooses to travel outside of the transportation service area in order to access a
preferred healthcare provider, the MCO shall review all requests and shall either issue a decision or submit a
written request for exception to LDH for approval. If LDH denies the request, the MCO shall deny the request and
will not be reimbursed for the trip. If LDH approves the request, the approval is valid for all of the enrollee’s
appointments to the specific healthcare provider or facility listed on the exception. If the physical location of the
healthcare provider or facility is modified, the approval is rendered invalid.
Enrollees may seek medically necessary services in another state when it is the nearest option available. All non-
emergency out-of-state transportation must be prior approved by the MCO. The MCO may approve transportation
to out-of-state medical care only if the enrollee has been granted approval to receive medical treatment out of
state.
Enrollees are linked to specific Opioid Treatment Program (OTP) locations; however, enrollees may receive opioid
treatment at another clinic (i.e., “guest dose”). The MCO shall cover transportation to any OTP location, not just
the location to which the enrollee is linked or that is in the enrollee’s home parish or region.
The MCO must maintain documentation to support exceptions to standards and submit documentation to LDH
upon request.
Exclusions
The MCO shall not be reimbursed for transportation to or from the following locations:
Pharmacies;
Nursing facilities;
Hospice care; or
Women, Infants, and Children (WIC) service appointments at the Office of Public Health.
NOTE: This is not an exclusive list.
The MCO may reimburse for transportation to or from a pharmacy, WIC appointment, or other value-added
benefit as an approved MCO value-added benefit, regardless if it is a standalone trip or as an additional stop. The
MCO shall flag both the service and the transportation as a value-added benefit in accordance with the MCO
System Companion Guide.
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Commercial Air Transportation for Out-of-State Care
The MCO may approve NEMT on commercial airlines for out-of-state trips when no comparable healthcare
services can be provided in Louisiana, and the risk to the enrollee’s health is grave if transported by other means.
All out-of-state non-emergency medical care must be prior authorized by the MCO. Transportation may be
included in the prior authorization for medical services. MCO approval shall be contingent on the treating
physician’s confirmation that there are no negative impacts to the health and safety of the enrollee by utilizing
commercial air transportation.
The MCO shall reimburse air travel for the enrollee plus a maximum of one attendant, if medically necessary or if
the enrollee is a child, at the lowest, refundable, coach/economy class fare. Upgrades (e.g., fare class or seat) and
additional costs (e.g., in-flight refreshments) shall not be reimbursed.
Scheduling and Dispatching
General Requirements
Requests for transportation may be made by enrollees or healthcare providers. The MCO may not impose a limit
on the number of NEMT services that may be scheduled by an enrollee or healthcare provider during a single call.
The transportation broker and the transportation provider may neither schedule, nor make changes to, an
enrollee’s healthcare appointment. Under no circumstances may the transportation broker or transportation
provider request that the enrollee change the date and/or time of a scheduled healthcare appointment. This
prohibition extends to healthcare providers who have an ownership interest in the transportation company.
To be eligible for reimbursement, NEMT trips must be reviewed by the MCO, prior to scheduling, for enrollee
eligibility and verification that the originating or destination address belongs to a medical facility. Additional
approval requirements for out-of-state travel and commercial air are addressed in this manual.
The MCO shall assign transportation providers on the basis of the least costly means available, including the use
of free and/or public transportation when possible, with consideration given to the enrollee’s choice of
transportation provider. The MCO shall ensure that the provider accommodates the level of service required to
safely transport the enrollee (e.g., ambulatory, wheelchair, transfer).
When multiple providers meet the least costly standard, the MCO should dispatch trips to providers whose
primary service region for operation, according to the provider’s Disclosure of Ownership Information Form for
Entity and Business, is the same as the enrollee’s domicile and who are able to comply with all travel and wait
time standards. The MCO is prohibited from dispatching trips to out-of-region providers, unless the MCO retains
documentation to support that there is no willing and available provider in the region
5
where the enrollee is
domiciled able to comply with time requirements or that the out-of-region provider is the least costly option.
With the exception of urgent transportation requests and discharges from inpatient facilities, enrollees and
healthcare providers are expected to give at least 48 hours’ notice when requesting transportation; however, the
MCO must make a reasonable attempt to schedule the trip with less than 48 hours’ notice.
5
Defined as the LDH administrative regions illustrated at https://ldh.la.gov/index.cfm/page/2.
MCO Manual | SERVICES | Medical Transportation 75
MCOs shall make every effort to schedule urgent transportation requests and may not deny a request based solely
on the appointment being scheduled less than 48 hours in advance. Urgent transportation refers to a request for
transportation made by a healthcare provider for a medical service which does not warrant emergency transport
but cannot be postponed. Urgent transportation shall include chemotherapy, radiation, dialysis, OTP, or other
necessary medical care that cannot be rescheduled to a later time. An urgent transportation request may occur
concurrently with a standing order.
NEMT providers shall pick up enrollees no later than three hours after notification by an inpatient facility of a
scheduled discharge or two hours after the scheduled discharge time, whichever is later. Examples are as
follows:
If an inpatient facility notifies the MCO at 12:00 pm for a 12:30 pm discharge, the enrollee shall be picked
up no later than 3 pm.
If an inpatient facility notifies the MCO at 12:00 pm for a 2 pm discharge, the enrollee shall be picked up
no later than 4 pm.
If an inpatient facility notifies the MCO at 8 pm for a 7 am discharge the next day, the enrollee shall be
picked up no later than 9 am.
The MCO shall allow enrollees who have recurring treatment and therapies, such as dialysis, chemotherapy, OTP,
or wound care, to establish a standing order for transportation. This allowance shall extend to the healthcare
facility providing the recurring treatment or therapies. The MCO shall assign transportation providers to the
standing order on the basis of the least costly means available. If multiple transportation providers meet the least
costly standard, the standing order should be scheduled with the same transportation provider to ensure
continuity of care and to prevent missed treatments.
The standing order shall be flexible, allowing the enrollee or healthcare facility to revise the pickup and/or drop-
off time, incorporate additional recurring appointments, and change the completion date of treatment. The MCO
shall update the standing order upon request of these changes and may not deny transportation associated with
these changes. MCOs shall review all standing orders at least once per calendar month to ensure the agreement
with the assigned transportation provider is the most cost-effective option available. Results of these reviews shall
be retained and made available to LDH upon request.
When a transportation provider cannot perform the service, the MCO shall require the provider to immediately
notify the MCO in order for the MCO to secure an alternate provider.
When the transportation broker is unable to fulfill an enrollee’s request for NEMT services after providing the
enrollee with a confirmation number for the requested transport, the MCO shall require the transportation broker
to notify the enrollee immediately that the transportation services will be canceled. The MCO shall require the
transportation broker to notify enrollees of any other changes to trip details. Notifications shall be provided via
phone, e-mail, or text, depending on the enrollee’s preferred method of communication.
The MCO shall monitor providers to ensure that they do not reject local trips in favor of long distance trips.
Providers who exhibit a pattern of rejecting local trips may be subject to trip reductions or other sanctions,
particularly if such action results in actual harm to an enrollee or places the enrollee at risk of imminent harm.
If a child is to be transported, either as the enrollee or an additional passenger, the parent or guardian of the child
is responsible for providing an appropriate child passenger restraint system as outlined by La. R.S. 32:295. The
MCO is responsible for notifying the parents or guardians of this requirement when scheduling the trip.
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Additional Passengers
The MCO must inform the transportation provider if an enrollee intends to bring accompanying children or if an
attendant is required.
The MCO shall prohibit transportation providers from charging the enrollee or anyone else for the transportation
of additional passengers and shall not reimburse any claims submitted for transporting additional passengers.
Children
The MCO’s policy must allow the transportation provider to refuse to transport accompanying children.
Attendants
The MCO is responsible for determining if an attendant is required. If required, the MCO shall ensure that the
attendant accompany the enrollee to and from the medical appointment. The following non-exclusive list of
conditions may require an attendant:
Sensory deficits;
Need for human assistance for mobility;
Dementia or other cognitive impairments;
At risk of elopement;
Behavioral disorders;
Need for interpretation or translation assistance; or
Special needs such as:
o Convalescence from surgical procedures;
o Decubitus ulcers or other problems which prohibit sitting for a long period of time;
o Incontinence or lack of bowel control;
o Assistance with toileting; and
o Artificial stoma, colostomy or gastrostomy.
An attendant shall be required when the enrollee is under the age of 17. This attendant must:
Be a parent, legal guardian, or responsible person designated by the parent/legal guardian; and
Be able to authorize medical treatment and care for the enrollee.
Attendants may not:
Be under the age of 17;
Be a Medicaid provider or employee of a Medicaid provider that is providing services to the enrollee being
transported, except for employees of a mental health facility in the event an enrollee has been identified
as being a danger to themselves or others or at risk for elopement; or
Be a transportation provider or an employee of a transportation provider.
Exceptions
All females, regardless of their age, seeking prenatal and/or postpartum care shall not be required to have an
attendant.
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Provider Requirements
Classification of Providers
NEMT is provided to Medicaid enrollees through four classifications of NEMT providers. The MCO shall consider
scheduling NEMT providers in the following order:
1. Public
2. Gas reimbursement
3. Non-profit
4. For-profit
Public providers include city and parish intrastate mass transit systems (e.g., bus, train).
Gas reimbursement providers are individuals, including friends or family members. The provider may not reside at
the same physical address as the enrollee being transported and may not transport more than five enrollees,
across all contracted MCOs, except where there are more than five enrollees in the same household.
Non-profit providers include those providers who are operated by or affiliated with a public organization such as
state, federal, parish or city entities, community action agencies, or parish Councils on Aging. If a provider qualifies
as a non-profit entity according to Internal Revenue Service (IRS) regulations, they may only enroll as non-profit
providers.
For-profit providers include corporations, limited liability companies, partnerships, or sole proprietors. For-profit
providers must comply with all state laws and the regulations of any governing state agency, commission, or local
entity to which they are subject as a condition of enrollment and continued participation in the Medicaid program.
General Requirements
The MCO shall ensure that the transportation provider agrees to cover the entire parish or parishes for which he
or she provides NEMT services.
The MCO shall ensure that the transportation provider performs door-to-door assistance to and from the main
entrance of the pickup and/or drop off locations upon request of enrollees who may require additional assistance.
The MCO shall ensure that the NEMT provider does not touch any passenger, unless the passenger requests
moderate assistance to, from, into, and out of the vehicle, including securing the seatbelt, and to and/or from the
entrance of the pick-up and drop-off location, unless such assistance would present a direct threat to the driver,
other passengers or individuals, or the vehicle.
Gas Reimbursement Provider Requirements
The MCO shall ensure that gas reimbursement providers are 18 years of age or older and possess a current
Louisiana driver’s license. The provider may not reside at the same address as the enrollee.
In order to be eligible for reimbursement, the MCO must obtain the following from gas reimbursement providers:
An enrollment form that includes at a minimum:
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o Provider’s full name;
o Provider’s physical address (P.O. Box is not valid);
o Provider’s mailing address;
o Provider’s phone number;
o Provider’s social security number; and
o List of no more than five enrollees or all enrollees within one household, for whom the driver may
be reimbursed. Enrollee information must include the full name, date of birth, and Medicaid ID;
A clear and legible copy of the valid driver’s license and attestation that a valid state inspection sticker will
be maintained as part of the enrollment packet; and
A copy of the vehicle’s registration and insurance that meets or exceeds the minimum insurance required
by the State of Louisiana.
Reimbursement to gas reimbursement providers is intended to cover all persons in the vehicle at the time of the
trip (i.e., reimbursement shall be made for one trip regardless of the number of enrollees or additional passengers
in the vehicle).
The MCO shall issue IRS Form 1099 to all gas reimbursement providers for income tax purposes.
For-Profit and Non-Profit Provider Requirements
The MCO shall obtain credentials from each for-profit and non-profit NEMT provider prior to and continually
thereafter providing services under the NEMT program. The MCO may not assign any trips to for-profit and non-
profit providers at any point who do not meet the requirements of this section. The MCO may not reimburse any
provider in violation of these requirements on the date of service. These requirements are not applicable to public
or gas reimbursement providers.
Each NEMT provider must meet all Medicaid program guidelines independently, regardless of whether more than
one NEMT provider is owned by the same NEMT provider entity.
Administrative Requirements
The MCO shall obtain the following administrative documents from the NEMT provider:
A Disclosure of Ownership Information Form for Entity and Business [link
] as required by 42 C.F.R. §§
455.104-455.106;
The provider’s National Provider Identifier (NPI) number in their business entity name obtained from the
National Plan and Provider Enumeration System (NPPES);
A copy of the IRS Form CP 575 showing the Employer Identification Number (EIN) and business entity
name which must match all other documentation including, but not limited to, vehicle signage. A copy of
the IRS Form 147C is acceptable if the IRS Form CP 575 is not available;
An IRS Form W-9 which matches the information on the IRS Form CP 575 or 147C;
A Certificate of Public Necessity (CPNC) issued by the Orleans Parish Taxicab Service and Enforcement
Bureau for each provider, driver, and vehicle that will operate in Orleans Parish; and
An NEMT permit issued by the Jefferson Parish Emergency Management Office for each provider, driver,
and vehicle that will operate in Jefferson Parish.
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The MCO shall conduct a search of Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE),
Louisiana Adverse Actions List Search, the System of Award Management (SAM), and other applicable sites as may
be determined by LDH, monthly to capture exclusions and reinstatements that have occurred since the previous
search. Any and all exclusion information discovered shall be reported to LDH within three business days. Any
individual or entity that employs or contracts with an excluded NEMT provider/individual cannot claim
reimbursement from Medicaid for any items or services furnished, authorized, or prescribed by the excluded
provider or individual. This is a prohibited affiliation. This prohibition applies even when the Medicaid
reimbursement itself is made to another provider who is not excluded.
The MCO is responsible for the return to the State of any money paid for services provided by an excluded NEMT
provider within 30 days of discovery. Failure by the MCO to ensure compliance with requirements to prevent and
return, as applicable, payments to excluded providers may also result in LDH assessing monetary penalties and/or
other remedies including, but not limited to, a deduction from the MCO's monthly capitation payment.
Insurance Requirements
The MCO shall ensure that for-profit and non-profit NEMT providers have general liability coverage if required by
a local ordinance in areas where the NEMT provider operates, in addition to automobile liability coverage of
$25,000 for bodily injury per person, $50,000 per accident, and $25,000 for property damages. Automobile liability
coverage should include either:
Symbols 7, 8, and 9; or
Symbols 2, 8, and 9.
The NEMT provider’s certificate of insurance must state that this coverage is for a Non-Emergency Medical
Transportation Vehicle. The policy must have a 30-day cancellation clause issued to the MCO. LDH must be listed
as an additional insured on the automobile liability and general liability policies. The MCO shall obtain a copy of
the policy from the provider.
If a transportation provider adds a vehicle, the MCO shall obtain from the NEMT provider an updated copy of the
policy, which shows that the additional vehicle is insured, prior to use of the vehicle.
The MCO shall ensure that all transportation companies carry worker’s compensation insurance as required by
Louisiana law.
Operation without the minimum insurance coverage is a violation of the NEMT provider requirements. LDH or the
MCO may recoup all payments for trips occurring during the period of violation.
Driver Requirements
Drivers shall meet the following minimum requirements in order to transport Medicaid enrollees:
Be 21 years of age or older;
Possess a current driver's license (class D or CDL);
Possess the appropriate municipal or parochial permits if operating in Orleans and Jefferson Parish;
Have an Official Driving Record with neither three or more moving violations, nor any convictions for
operating a vehicle while intoxicated, within the past three years;
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Comply with La. R.S. 40:1203.1 - 40:1203.7. Transportation providers shall conduct an annual criminal
history check on all NEMT drivers. The criminal history check must be performed by the Louisiana State
Police, an agency authorized by the Louisiana State Police, or the FBI. The results of the criminal history
check must be transmitted directly to the MCO or its transportation broker by the authorizing agency. The
driver must submit written consent allowing the authorized agency to release the background check
results directly to the MCO and transportation broker. The driver must have a “clean” record, with no
convictions for prohibited crimes, unless the person has received a pardon of the conviction or has had
their conviction expunged; and
Have successfully passed a five-panel drug screen, at a minimum, which shall be performed annually and
upon reasonable suspicion. The results of the drug screen must be transmitted directly to the MCO by the
testing agency. Any driver, or prospective driver, who fails the drug screen may resume driver
responsibilities after a substance abuse professional issues a final evaluation and return to work clearance.
The MCO shall confirm that the driver successfully completes three follow-up screens over the six-month
period following return to duty.
The MCO shall obtain documentation demonstrating compliance with these requirements.
Training Requirements
NEMT drivers shall complete the following training requirements prior to transporting any Medicaid enrollees:
Defensive driving, utilizing an in-person or virtual course of no less than four hours, to be renewed every
three years, at a minimum;
Cardiopulmonary resuscitation (CPR), utilizing an in-person course, culminating in an active certification
issued by a licensed instructor;
Child passenger restraint systems, including installation and usage in compliance with La. R.S. 32:295;
Wheelchair securement and Passenger Assistance Safety and Sensitivity (PASS), to be renewed every two
years, at a minimum, and as follows:
o All drivers contracted with NEMT providers who do not have wheelchair accessible vehicles within
their fleet may take virtual wheelchair securement training;
o All drivers contracted with NEMT providers who have wheelchair accessible vehicles, regardless
of whether they are lift vehicles or ramp vehicles, are required to take in-person wheelchair
securement training;
o Any driver that has a valid ADA exception, diagnosed by a healthcare provider, which excludes
them from all wheelchair transports, may take either the in-person or virtual wheelchair
securement training. The driver shall not drive any wheelchair accessible vehicles when
transporting Medicaid enrollees; and
Health Insurance Portability and Accountability Act (HIPAA) privacy and security.
The MCO shall obtain supporting documentation and ensure compliance with driver training requirements.
Vehicle Requirements
The MCO shall ensure that each vehicle authorized to transport enrollees under the NEMT program attains
compliance with all vehicle requirements prior to transporting any Medicaid enrollees and maintains compliance
thereafter.
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General Requirements
The transportation provider shall own or lease its vehicles. The MCO shall obtain documentation that the vehicle
is registered in the name of the company. The MCO must ensure each leased vehicle meets all Medicaid Program
requirements, including insurance requirements, set forth by LDH. The MCO must ensure each leased vehicle
meets all insurance requirements set forth specifically for leased vehicles by the State of Louisiana and the Office
of Motor Vehicles.
The MCO shall ensure that vehicles meet the following minimum requirements:
Windshield in good condition and free of vision impairments;
Active LA inspection sticker or, if applicable, the inspection sticker for vehicles operating in Orleans and
Jefferson Parish;
Certificate of Public Necessity and Convenience (CPNC) for each vehicle operating in New Orleans and
NEMT permit for each vehicle operating in Jefferson Parish;
Signage on the appropriate sides of the vehicle (see Signage);
License plate, with an active registration sticker;
Vehicle Identification Number (VIN) on a portion of the vehicle;
Registration and insurance card secured in the vehicle;
Functioning air conditioning and heating in the front and rear of the vehicle;
Functioning seatbelts;
Seat belt cutter secured in the vehicle within the driver’s reach;
Fire extinguisher, showing the pressure gauge is reading within the manufacturer’s optimal setting,
secured in the vehicle; and
MCO or its transportation broker’s decal, displaying the date the vehicle passed inspection, attached to
the vehicle.
NEMT providers may not share vehicles with other NEMT providers regardless of whether more than one NEMT
provider is owned by the same NEMT provider entity.
Stretcher vans, two-door vehicles, and pickup trucks are not allowable vehicle types. Salvage title vehicles are also
not allowed.
If the vehicle is equipped to transport wheelchairs, the MCO must ensure that it complies with all applicable
Americans with Disabilities Act (ADA) requirements, including requirements for restraints, tie-downs, lifts, and
ramps.
The MCO shall require NEMT providers to notify the MCO of any newly added vehicles in order for the MCO to
properly inspect and credential the vehicle prior to use within the NEMT Program. Providers must submit copies
of vehicle registration and Certificate of Insurance (COI) for all newly added vehicles. Providers operating in New
Orleans or Jefferson Parish must also submit copies of their appropriate municipal or parochial permits.
The MCO shall require NEMT providers to follow all LDH-approved transportation policies, including those
established by a transportation broker. The MCO shall include in its policies a protocol for handling and
documenting enrollee “no shows” (i.e., when the enrollee is not present for pick-up at the specified location).
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Signage
Each vehicle must have signage that displays the name and the telephone number of the enrolled provider and
the vehicle number. The signage must be located on the driver side, passenger side, and, if a van, on the rear of
the vehicle. Signs must not be affixed to the windows where they would interfere with the vision of the driver.
Vehicles funded by the Louisiana Department of Transportation and Development (DOTD) are required to have
the DOTD transit logo displayed on them. This logo will be accepted as appropriate signage for enrollment in the
NEMT program.
Vehicles operating in Orleans Parish must use their Orleans Parish Certificate of Public Necessity and Convenience
(CPNC) number as their vehicle number. The CPNC number must meet Orleans Parish regulations for size, contrast
of color, and location.
License Plates
Each NEMT vehicle must have a “for hire”, “public”, or “public handicapped” license plate, in accordance with La.
R.S. 45:181 and 49:121. The vehicle must be licensed in the provider’s business name when obtaining the license
plate.
Vehicle Inspections
The MCO must perform an inspection prior to the vehicle being placed into the NEMT Program and annually
thereafter.
The inspection must ensure that the vehicle meets all items covered under the Louisiana Highway Regulatory Act
and functions as intended by the manufacturer.
Vehicle inspections shall be documented electronically and include digitized photographs evidencing that
requirements have been met, including, but not limited to:
Each side of the vehicle and appropriate signage;
LA inspection sticker which should also include the vehicle VIN;
Clear and legible license plate, registration sticker, VIN, and registration and insurance cards;
Location of the seat belt cutter and fire extinguisher, including a pressure gauge reading;
Active use of a temperature gun directed at a vent measuring the temperature of the air
conditioning/heating of the front vent and rear vent, when one is present, of the vehicle. The reading
should be no hotter than 52 degrees Fahrenheit when measuring the air conditioning nor cooler than 100
degrees Fahrenheit when measuring the heater;
Interior of the vehicle showing all seat belts secured properly; and
The MCO’s decal, displaying the date the vehicle passed inspection, attached to the vehicle.
If the vehicle is equipped to transport wheelchairs, the inspector shall ensure that the wheelchair lift and all
backup mechanisms are in working order. Digital photographs of the following are also required:
Wheelchair secured showing proper application of the securements to the base; and
Wheelchair shoulder and lap belt properly secured with the wheelchair in frame for reference.
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All vehicle identifying information must be captured during the inspection to include VIN, year, make, model,
vehicle color, license plate number, date of inspection, name and signature of inspector, and inspection results.
Unannounced Compliance Reviews
In an ongoing effort to identify and remedy non-compliant behavior, LDH or the MCO may perform unannounced
vehicle compliance reviews. During these reviews, NEMT providers may be monitored for driver, vehicle, and
program compliance which includes, but is not limited to, the examination of all provider manifests, signature
pages, drivers’ licenses, vehicle registration, insurance cards, vehicle safety checks, etc. Non-compliance with any
of the aforementioned may result in sanctions, suspension, and/or exclusion from the LA Medicaid Program.
Providers do NOT have the right to refuse an unannounced compliance review.
Provider Responsibilities
The MCO shall ensure that transportation providers comply with the following provider responsibilities for all
NEMT services within this section.
Travel and Wait Times
Transportation providers must perform services in a timely and professional manner. The MCO shall ensure that
providers meet the following standards:
Enrollees must arrive at least 15 minutes, but no more than two hours, prior to their appointments;
If the transportation provider arrives prior to the healthcare provider’s business hours, the transportation
provider shall remain with the enrollee until the business opens;
Upon completion of the appointment, enrollees shall be picked up within the healthcare provider’s
business hours and:
o For prescheduled pick-ups, no more than two hours after the appointment has concluded; or
o For enrollees using the will-call option for the return trip, no more than two hours after the will-
call request; and
Enrollees shall not be in the vehicle for more than one hour beyond the estimated travel time.
Vehicle Operation Requirements, Safety, and Professionalism
The MCO shall ensure that drivers project responsible, professional, and courteous behavior by monitoring
compliance of the following requirements.
Drivers must exercise the utmost safety in caring for enrollees while transporting them and guard against
becoming insensitive to their physical and emotional conditions.
Drivers must ensure:
The equipment and vehicle used are kept clean and serviceable at all times;
All laws of the State of Louisiana are observed while transporting passengers; and
The vehicle is safe and in good operating condition.
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NOTE: A vehicle must not be driven unless the driver determines that the following parts and accessories are in good working
order: vehicle brakes, parking brakes, steering mechanism, lighting devices and reflectors, tires, horn, windshield wipers, and
mirrors.
Drivers must:
Not use or be under the influence of alcohol within four hours before going on duty or while operating,
or having physical control of, a vehicle.
Not be under the influence of an amphetamine of any formulation thereof, a narcotic drug or any
derivative thereof, or other substance to a degree which renders the driver incapable of safely operating
a vehicle.
Not use or be under the influence of marijuana, including therapeutic or medical marijuana as permitted
by state law, while operating, or having physical control of, a vehicle. The crossing of state lines with
medical marijuana as well as the unlawful distribution, dispensation, possession, or use of marijuana in
the workplace is otherwise prohibited.
Come to a complete stop at all railroad crossings.
Utilize the proper procedures required to move enrollees into and out of the vehicle equipped to transport
non-ambulatory, wheelchair enrollees.
Ensure that all passengers are wearing seatbelts or are otherwise secured. If the passenger uses a
wheelchair during transport, the driver must ensure the appropriate use of an occupant restraint system.
Lap positioning belts and chest straps are not sufficient safety restraints for wheelchair passengers.
Ensure that no smoking or vaping occurs in the vehicle as in accordance with current Occupational, Safety
and Health Administration (OSHA) regulations.
Always turn the engine off when fueling a motor vehicle, and never fuel the vehicle where there is smoke
or an open flame.
Ensure that vehicles are not towed or pushed with passengers on board.
Drivers shall ensure the proper installation and usage of the child passenger restraint systems in compliance with
La. R.S. 32:295. Non-compliance with these laws may result in immediate suspension and/or removal of the driver
and/or provider.
Emergency Action Procedure
If an emergency arises while transporting an enrollee, the driver must immediately assess the situation and
determine whether to:
Stop the vehicle and assist with the emergency;
Proceed immediately to the nearest medical facility; or
Call 911 for emergency medical assistance.
If the enrollee is taken to an emergency medical facility, the driver must immediately notify the MCO or its
transportation broker and a member of the enrollee’s family. When driving to the emergency medical facility, the
driver should remain calm and alert and drive as quickly as conditions permit for safe vehicle operation.
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Incident Reporting Requirements
Drivers who are involved in an incident shall notify emergency services immediately and in accordance with La.
R.S. 32:398.
The transportation provider must report the following to the MCO:
Reporting Requirements
Reporting Period
For all motor vehicle accidents:
• Time, date, location, and summary of incident;
• Provider name;
• Driver and vehicle information;
• Enrollee name, Medicaid ID number, and contact information;
• Name and contact information for all other passengers;
• Injuries sustained;
• Names and contact information of witnesses;
• Any police issued citations or summons; and
• Results of drug screen which was conducted within 12 hours of
the incident.
Within 72 hours of the accident
Copy of the Louisiana Uniform Motor Vehicle Accident Report
Within 15 business days of the accident
Written report of all incidents when a Medicaid enrollee dies or is injured
while in the provider’s care, regardless of the cause
Within 72 hours of the incident
If the MCO contracts with a transportation broker, the transportation broker shall provide a detailed accounting
of each incident to the MCO upon notification by the provider.
Record Keeping
The MCO shall require transportation providers to maintain sufficient documentation to identify the enrollees
transported, trips made, locations traveled, driver qualifications, vehicle capabilities, and safety information.
Daily Trip Log
The MCO shall obtain a daily trip log from for-profit and non-profit providers that captures the following
information:
Trip identification number;
Enrollee’s name, Medicaid ID number, address, and signature;
Destination address;
Healthcare provider or facility’s name, if applicable;
Departure date and time;
Arrival date and time;
Driver’s name;
VIN; and
Any other comments regarding the trip.
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The daily trip log shall be maintained in electronic format and sorted chronologically.
Prior to reimbursement, the MCO shall verify that each claim from a for-profit or non-profit provider has a
corresponding entry in the daily trip log.
Gas Reimbursement Form
The MCO shall obtain a gas reimbursement form for every NEMT claim from a gas reimbursement provider to be
eligible for reimbursement. The gas reimbursement form must be typed or written in ink and include the following
information:
Trip identification number;
Driver’s full name;
Driver’s residential address;
Driver’s phone number;
Driver’s e-mail address (if applicable);
Driver’s relationship to enrollee;
Enrollee’s name;
Enrollee’s Medicaid ID number;
Enrollee’s address;
Transportation date;
Name of facility/medical provider;
Address of facility/medical provider;
Phone number of facility/medical provider;
Signature of driver attesting that the information on the form is true and correct;
Signature of enrollee or parent/guardian attesting that the information on the form is true and correct;
Medical facility/physician’s signature and date; and
Medical facility’s stamp.
Prior to reimbursement, the MCO shall verify that each claim from a gas reimbursement provider has a
corresponding and properly completed gas reimbursement form.
Claims and Encounters
Claims Filing
Transportation providers shall submit all transportation claims to the MCO. Claims shall be submitted within 365
days of the date of service.
The MCO shall maintain a system that accepts electronic claim submissions and may not require providers to
submit paper claims.
Encounter Submissions
The MCO shall submit encounters in compliance with the contract and the MCO System Companion Guide.
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The MCO shall flag value-added benefits in accordance with the MCO System Companion Guide.
Ambulance
Ambulance transportation is emergency or non-emergency medical transportation provided to Medicaid
enrollees to and/or from a Medicaid covered service or VAB by ground or air ambulance when the enrollee’s
condition is such that use of any other method of transportation is contraindicated or would make the enrollee
susceptible to injury.
To participate in the Medicaid program, ambulance providers must meet the requirements of La. R.S. 40:1135.1 -
1135.4. Licensing by the LDH Bureau of Emergency Medical Services is also required. Services must be provided in
accordance with state law and regulations governing the administration of these services. Additionally, licensure
is required for the medical technicians and other ambulance personnel by the LDH Bureau of Emergency Medical
Services.
The MCO shall require all ambulance providers, including NEAT providers, to maintain insurance, including but
not limited to Medical Malpractice Liability, Automobile Liability, Commercial General Liability, and Workers’
Compensation Indemnity, in accordance with La. R.S. 40:1135.9 and any applicable federal or state law or local
ordinance.
Reimbursement to ambulance providers shall be no less than the published Medicaid FFS rate in effect on the
date of service, unless mutually agreed upon by the MCO or its transportation broker and the transportation
provider in the provider agreement.
Terms utilized in the published Medicaid fee schedule are defined as follows:
Basic Life Support (BLS)
6
: The provision of medically necessary supplies and services by EMS practitioners
who are licensed at least to the level of emergency medical technician.
Advanced Life Support (ALS)
7
: The provision of medically necessary supplies and services by EMS
practitioners who are licensed at least to the level of advanced emergency medical technician or
equivalent.
Specialty Care Transport
8
: Interfacility transportation of a critically injured or ill beneficiary by a ground
ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the
scope of the EMT-Paramedic.
The MCO shall reimburse ambulance providers for mileage to the nearest appropriate facility. Reimbursement for
mileage will vary depending on whether the transport is for an emergency or non-emergency event.
Reimbursement for mileage shall be limited to actual mileage from point of pick up to point of delivery. Mileage
can only be reimbursed for miles traveled with the enrollee in the ambulance.
Reimbursement for transportation of ambulance staff, medical staff, or other personnel when the enrollee is not
onboard the ambulance, both ground and air, is prohibited. This prohibition does not apply to reimbursement for
physician directed treatment-in-place ambulance services.
6
Defined by La. R.S. 40:1131.
7
Defined by La. R.S. 40:1131.
8
Defined by 42 C.F.R. § 414.605.
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Refer to the Hospital Services section of this Manual for policies related to hospital-based ambulance services.
Emergency Ambulance Transportation
Emergency ambulance transportation is provided for a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the
following:
Placing the health of the enrollee (or, with respect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy;
Serious impairment to bodily functions; or
Serious dysfunction of any bodily organ or part.
An enrollee may also require emergency ambulance transportation if he or she is psychiatrically unmanageable
or needs restraint.
The MCO shall ensure that ambulance providers retain documentation that appropriately supports that at least
one of these criteria was met and that the enrollee would be susceptible to injury using any other method of
transportation. An ambulance trip that does not meet at least one of these criteria would be considered a
nonemergency service and must be coded and billed as such.
The MCO may not require prior review or authorization for emergency ambulance transportation. The MCO may
conduct a post-payment review after service delivery. Claims for payment of emergency ambulance
transportation services is received and reviewed retrospectively. Clinical documentation to support emergency
ambulance transportation services shall not be required for submission concurrent with the claim. If required by
the MCO, clinical documentation shall be required post claim submission.
The MCO shall reimburse for oxygen and disposable supplies separately when medically necessary.
Treatment-in-Place
Physician directed treatment-in-place service is the facilitation of a telehealth visit by an ambulance provider.
Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place
telehealth claim, and each paid treatment-in-place telehealth claim must have a separate and corresponding paid
treatment-in-place ambulance claim or a separate and corresponding paid ambulance transportation claim. The
MCO may not reimburse for both an emergency transport to a hospital and an ambulance treatment-in-place
service for the same incident.
Treatment-in-Place Ambulance Services
The MCO shall restrict payment of treatment-in-place ambulance services to those identified on the Physician
Directed Ambulance Treatment-in-Place Fee Schedule and edit claims for non-payable procedure codes as follows:
If a treatment-in-place ambulance claim is billed with mileage, the MCO shall deny the entire claim
document.
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If an unpayable procedure code, that is not mileage, is billed on a treatment-in-place ambulance claim,
the MCO shall deny only the line with the unpayable code.
Claims for allowable telehealth procedure codes must be billed with procedure code G2021. The G2021
code shall be accepted, paid at $0.00, and used by the MCO to identify treatment-in-place telehealth
services.
As with all telehealth claims, providers must include POS identifier “02” or “10” and modifier "95" with
their claim to identify the claim as a telehealth service. Providers must follow CPT guidance relative to the
definition of a new patient versus an established patient.
Valid treatment-in-place ambulance claim modifiers include:
Modifier
Origination Site
Destination
DW
Diagnostic or therapeutic site other than P or H when these are used as origin codes
Tx-in-Place
EW
Residential, domiciliary, custodial facility (other than 1819 facility)
Tx-in-Place
GW
Hospital based ESRD facility
Tx-in-Place
HW
Hospital
Tx-in-Place
IW
Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
Tx-in-Place
JW
Freestanding ESRD facility
Tx-in-Place
NW
Skilled nursing facility
Tx-in-Place
PW
Physician’s office
Tx-in-Place
RW
Residence
Tx-in-Place
SW
Scene of accident or acute event
Tx-in-Place
If an enrollee being treated-in-place has a real-time deterioration in their clinical condition necessitating
immediate transport to an emergency department, as determined by the ambulance provider (i.e., EMT or
paramedic), telehealth provider, or enrollee, the MCO may not reimburse for both the treatment-in-place
ambulance service and the transport to the emergency department. In this situation, the MCO shall reimburse
for the emergency department transport only. The MCO shall require ambulance providers to submit pre-hospital
care summary reports when ambulance treatment-in-place and ambulance transportation claims are billed for
the same enrollee with the same date of service.
If an enrollee is offered treatment-in-place services but declines the services, ambulance providers should include
procedure code G2022 on claims for ambulance transportation to an emergency department. Use of this
informational procedure code is optional and does not affect the establishment of medical necessity of the service
or reimbursement of the ambulance transportation claim. The G2022 code shall be accepted, paid at $0.00, and
used by the MCO to identify enrollee refusal of treatment-in-place services.
Treatment-in-Place Telehealth Services
The MCO shall restrict payment of treatment-in-place telehealth services to those identified on the Treatment-in-
Place Telehealth Services Fee Schedule.
Valid rendering providers are licensed physicians, advanced practice registered nurses, and physician assistants.
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Ambulance Service Exclusions
Medicaid does not cover “Ambulance 911-Non-emergency” services. If the enrollee’s medical condition does not
present itself as an emergency in accordance with the criteria in this Manual, the service may be considered a
non-covered service by Medicaid.
Ambulance providers shall code and bill such non-emergency services using modifiers GY, QL, or TQ to indicate
that the services performed were non-covered Medicaid services.
The MCO may allow ambulance providers to bill enrollees for non-covered services only if the enrollee was
informed prior to transportation, verbally and in writing, that the service would not be covered by Medicaid and
the enrollee agreed to accept the responsibility for payment. The MCO shall ensure that the provider obtains a
signed statement or form which documents that the enrollee was verbally informed of the out-of-pocket expense.
Emergency Action Procedure
If a medical emergency arises while transporting an enrollee, the ambulance driver must immediately assess the
situation and determine whether to proceed immediately to the closest, most appropriate healthcare facility. If
the enrollee is taken to an emergency medical facility, the ambulance driver must notify the MCO or its
transportation broker within 48 hours of the transport.
Non-Emergency Ambulance Transportation
Non-emergency ambulance transportation (NEAT) is transportation provided by ground or air ambulance to a
Medicaid enrollee to and/or from a Medicaid covered service, including carved-out services, or value-added
benefits (VAB) when no other means of transportation is available and the enrollee’s condition is such that use of
any other method of transportation is contraindicated or would make the enrollee susceptible to injury. The
nature of the trip is not an emergency, but the enrollee requires the use of an ambulance.
Certification of Ambulance Transportation
The enrollee’s treating physician, a registered nurse, the director of nursing at a nursing facility, a nurse
practitioner, a physician assistant, or a clinical nurse specialist must certify on the Certification of Ambulance
Transportation (CAT) that the transport is medically necessary and describe the medical condition which
necessitates ambulance services. The certifying authority shall complete the date range on the CAT, which shall
be no more than 180 days. A single CAT should be utilized by the MCO for all of the enrollee’s transports within
the specified date range. The MCO may not require a new CAT from the certifying authority for the same enrollee
during this date range.
NEAT must be scheduled by the enrollee or a medical facility through the MCO or the ambulance provider.
If transportation is scheduled through the MCO, the MCO shall verify the following prior to scheduling:
enrollee eligibility, that the originating or destination address belongs to a medical facility, and that a
completed Certification of Ambulance Transportation form for the date of service is obtained, reviewed,
and accepted by the MCO or its transportation broker. Once the trip has been dispatched to an ambulance
MCO Manual | SERVICES | Medical Transportation 91
provider and completed, the ambulance provider shall be reimbursed upon submission of the clean claim
for the transport.
If transportation is scheduled through the ambulance provider, the MCO shall require the ambulance
provider to verify the following prior to reimbursement: enrollee eligibility, that the originating or
destination address belongs to a medical facility, and that a completed Certification of Ambulance
Transportation form for the date of service is obtained, reviewed, and accepted by the ambulance
provider. The MCO shall reimburse the ambulance provider only if a completed Certification of Ambulance
Transportation form is submitted with the clean claim or is on file with the MCO or its transportation
broker prior to reimbursement.
Mileage must be reimbursed in accordance with the type of service indicated by the licensed medical professional
on the Certification of Ambulance Transportation.
The Certification of Ambulance Transportation form is located at www.lamedicaid.com [link
].
Out-of-State Transportation
Enrollees may seek medically necessary services in another state when it is the nearest option available. All out-
of-state NEAT transportation to facilities that are not the nearest available option, must be prior approved by the
MCO. The MCO may approve transportation to out-of-state medical care only if the enrollee has been granted
approval to receive medical treatment out of state.
The MCO must maintain documentation to support compliance with these standards and must submit
documentation to LDH upon request.
Scheduling and Dispatching
MCOs shall make every effort to schedule urgent transportation requests and may not deny a request based solely
on the appointment being scheduled less than 48 hours in advance. Urgent transportation refers to a request for
transportation made by a healthcare provider for a medical service which does not warrant emergency transport
but cannot be postponed. Urgent transportation shall include chemotherapy, radiation, dialysis, OTP, or other
necessary medical care that cannot be rescheduled to a later time. An urgent transportation request may occur
concurrently with a standing order.
Additional Passengers
The MCO shall prohibit ambulance providers from charging the enrollee or anyone else for the transportation of
additional passengers and shall not reimburse any claims submitted for transporting additional passengers.
Attendants
An attendant shall be required when the enrollee is under the age of 17. This attendant must:
Be a parent, legal guardian, or responsible person designated by the parent/legal guardian; and
Be able to authorize medical treatment and care for the enrollee.
Attendants may not:
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Be under the age of 17; or
Be a Medicaid provider or employee of a Medicaid provider that is providing services to the enrollee being
transported, except for employees of a mental health facility in the event an enrollee has been identified
as being a danger to themselves or others or at risk for elopement.
Exceptions
All females, regardless of their age, seeking prenatal and/or postpartum care shall not be required to have an
attendant.
Nursing Facility Ambulance Transportation
Nursing facilities are required to provide medically necessary transportation services for Medicaid enrollees
residing in their facilities. Any nursing facility enrollee needing non-emergency, non-ambulance transportation
services are the financial responsibility of the nursing facility. NEAT services provided to a nursing facility enrollee
must include the Certification of Ambulance Transportation, in accordance with the Coverage Requirements
section, to be reimbursable by the MCO; otherwise, the nursing facility shall be responsible for reimbursement
for such services.
Air Ambulance
Air ambulances may be used for emergency and non-emergency ambulance transportation when medically
necessary. Licensure by the LDH Bureau of Emergency Medical Services is also required. Licensure for air
ambulance services is governed by La. R.S. 40:1135.8. Rotor winged (helicopters) and fixed winged emergency
aircraft must be certified by BHSF in order to receive Medicaid reimbursement.
All air ambulance services must comply with State laws and regulations governing the personnel certifications of
the emergency medical technicians, registered nurses, respiratory care technicians, physicians, and pilots as
administered by the appropriate agency of competent jurisdiction.
The MCO shall cover air ambulance services only if:
Speedy admission of the enrollee is essential and the point of pick-up of the enrollee is inaccessible by a
land vehicle; or
Great distances or other obstacles are involved in getting the enrollee to the nearest hospital with
appropriate services.
If both ground and air ambulance transports are necessary during the same trip, the MCO shall reimburse each
type of provider separately according to regulations for that type of provider.
Ambulance Memberships
The MCO shall prohibit ambulance companies that are enrolled in Medicaid from soliciting Medicaid enrollees for
membership fees for a subscription plan. Solicitation of such fees is a violation of Section 1916 of the Social
Security Act and regulations at 42 C.F.R. §§ 447.15 and 447.56. If such membership fees are collected, the
Medicaid enrollee must be refunded in full, or the ambulance provider will be terminated from the program.
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It is not a violation of the regulations when a Medicaid-enrolled ambulance company accepts membership fees if
the Medicaid enrollee voluntarily subscribes to the plan.
If a Medicaid-enrolled ambulance company’s subscription plan operates as an insurance policy, and the Medicaid
enrollee pays the fee, the fee is treated as an insurance premium and is not in violation of Medicaid regulations.
Return Trips and Transfers
Return Trips
When an enrollee is transported to a hospital by ambulance on an emergency basis and is not admitted, the
hospital shall request an NEMT return trip with the MCO unless the enrollee meets the medical necessity
requirements for NEAT.
Transfers
An ambulance transfer is the transport of an enrollee by ambulance from one hospital to another. The MCO shall
only cover ambulance transfers when it is medically necessary for the enrollee to be transported by ambulance.
The enrollee must be transported to the most appropriate hospital that can meet their needs.
If the physician makes the decision that the level of care required by the enrollee cannot be provided by the
hospital, and the enrollee has to be transported by the provider to another hospital, the MCO shall reimburse the
transportation provider for both transfers once clean claims are submitted for the transfers.
Claims and Encounters
Claims Filing
Ambulance providers shall submit claims using the CMS 1500 Health Insurance Claim Form (paper) or the 837P
(electronic).
Ambulance providers shall submit claims for ambulance transportation to the MCO.
Claims shall be submitted within 365 days of the date of service.
Medicaid and Medicare Part B
Services for Medicare Part B enrollees should be billed to the Medicare carrier on the Medicare claim form.
Medicare will make payment and cross the claim over to the MCO for Title XIX payment.
Medicaid will not make payment on any claim denied by Medicare as not being medically necessary. Qualified
Medicare Beneficiary (QMB) claims are included in this policy.
For trips that are not covered by Medicare but are covered by Medicaid, payment will not be made unless the
claim is filed with the Medicare EOB attached stating the reason for denial by Medicare.
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For claims that fail to cross over electronically, a hard-copy claim may be filed up to six months after the date of
the Medicare EOB, provided that the claim was filed with Medicare within a year of the date of service.
Medicaid does a cost comparison of cross-over claims to determine if Medicare paid more than Medicaid for the
claim. If this occurs and Medicare has paid more than Medicaid reimburses for the service, the claim will be “zero”
paid and the ambulance provider will be considered paid in full. No balance may be collected from the enrollee.
Ambulance Transportation Modifiers
When billing for procedure codes A0425-A0429, A0433-A0434, and A0436 for ambulance transportation services,
the MCO shall require the provider to also enter a valid 2-digit modifier at the end of the associated 5-digit
procedure code. Different modifiers may be used for the same procedure code. Spaces will not be recognized as
a valid modifier for those procedures requiring a modifier.
The following table identifies the valid modifiers.
Modifier
Description
DD
Trip from DX/Therapeutic Site to another DX/Therapeutic Site
DE
Trip from DX/Therapeutic Site to Residential, Domiciliary, Custodial Facility
DH
Trip from DX/Therapeutic Site to Hospital
DI
Diagnostic-Therapeutic Site/Transfer Airport Heli Pad
DJ
Diagnostic/therapeutic site other than P/H to a Non-Hospital-based Dialysis facility
DN
Trip from DX/Therapeutic Site to Skilled Nursing Facility (SNF)
DP
Trip from DX/Therapeutic Site to Physician’s Office
DR
Trip from DX/Therapeutic Site to Home
DX
Trip from DX/Therapeutic Site to MD to Hospital
ED
Trip from an RDC or Nursing home to DX/Therapeutic Site
EH
Trip from an RDC or Nursing home to Hospital
EG
Trip from an RDC or Nursing home to Dialysis Facility (Hospital based)
EI
Residential Domicile Custody Facility/Transfer Airport Heli Pad
EJ
Trip from an RDC or Nursing home to Dialysis Facility (non-Hospital based)
EN
Trip from an RDC or Nursing home to SNF
EP
Trip from an RDC or Nursing home to Physician’s Office
ER
Trip from an RDC or Nursing home to Physician’s Office
EX
Trip from RDC to MD to Hospital
GE
Trip from HB Dialysis Facility to an RDC or Nursing Home
GG
Trip from HB Dialysis Facility to Dialysis Facility (Hospital Based)
GH
Trip from HB Dialysis Facility to Hospital
GI
HB Dialysis Facility/Transfer Airport Heli Pad
GJ
Trip from HB Dialysis Facility to Dialysis Facility (non-Hospital Based)
GN
Trip from HB Dialysis Facility to SNF
GP
Trip from HB Dialysis Facility to Physician’s Office
GR
Trip from HB Dialysis Facility to Patient’s Residence
GX
Trip from HB Dialysis Facility to MD to Hospital
HD
Trip from Hospital to DX/Therapeutic Site
HE
Trip from Hospital to an RDC or Nursing Home
HG
Trip from Hospital to Dialysis Facility (Hospital Based)
HH
Trip from One Hospital to Another Hospital
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Modifier
Description
HI
Hospital/Transfer Airport Heli Pad
HJ
Trip from Hospital to Dialysis Facility
HN
Trip from Hospital SNF
HP
Trip from Hospital to Physician’s Office
HR
Trip from Hospital to Patient’s Residence
IH
Transfer Airport Heli Pad/Hospital
II
Site of Ambulance transport modes transfer to another Site of Ambulance transport modes transfer
JD
Non-Hospital-based Dialysis facility to a Diagnostic/therapeutic site other than P/H
JE
Trip from NHB Dialysis Facility to RDC or Nursing Home
JG
Trip from NHB Dialysis Facility to Dialysis Facility (Hospital Based)
JH
Trip from NHB Dialysis Facility to Hospital
JI
NHB Dialysis Facility/Transfer Airport Heli Pad
JN
Trip from NHB Dialysis Facility to SNF
JP
Trip from NHB Dialysis Facility to Physician’s Office
JR
Trip from NHB Dialysis Facility to Patient’s Residence
JX
Trip from NHB Dialysis Facility to MD to Hospital
ND
Trip from SNF to DX/Therapeutic Site
NE
Trip from SNF to an RDC or Nursing Home
NG
Trip from SNF to Dialysis Facility (Hospital based)
NH
Trip from SNF to Hospital
NI
Skilled Nursing Facility/Transfer Airport Heli Pad
NJ
Trip from SNF to Dialysis Facility (non-Hospital based)
NN
Trip from SNF to SNF
NP
Trip from SNF to Physician’s Office
NR
Trip from SNF to Patient’s Residence
NX
Trip from SNF to MD to Hospital
PD
Trip from a Physician’s Office to DX/Therapeutic Site
PE
Trip from a Physician’s Office to an RDC or Nursing Home
PG
Trip from a Physician’s Office to Dialysis Facility (Hospital based)
PH
Trip from a Physician’s Office to a Hospital
PI
Physician’s Office/Transfer Airport Heli Pad
PJ
Trip from a Physician’s Office to Dialysis Facility (non-Hospital based)
PN
Ambulance trip from the Physician’s Office to Skilled Nursing Facility
PP
Ambulance trip from Physician to Physician’s Office
PR
Trip from Physician’s Office to Patient’s Residence
RD
Trip from the Patient’s Residence to DX/Therapeutic Site
RE
Trip from the Patient’s Residence to an RDC or Nursing Home
RG
Trip from the Patient’s Residence to Dialysis Facility (Hospital based)
RH
Trip from the Patient’s Residence to a Hospital
RI
Residence/Transfer Airport Heli Pad
RJ
Trip from the Patient’s Residence to Dialysis Facility (non-Hospital based)
RN
Trip from the Patient’s Residence to Skilled Nursing Facility
RP
Trip from the Patient’s Residence to a Physician’s Office
RX
Trip from Patient’s Residence to MD to Hospital
SH
Trip from the Scene of an Accident to a Hospital
SI
Accident Scene, Acute Event/Transfer Airport, Heli Pad
TN
Rural Area
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Emergency ambulance claims, that are not treatment-in-place, are only payable with a destination modifier of H,
I, or X. Valid treatment-in-place ambulance claim modifiers are identified in the Treatment-in-Place section.
Medicaid Non-Covered Ambulance Modifiers
The MCO shall have edits in place to deny ambulance claims as non-covered services when any of the following
modifiers are billed on the claim, in any modifier field.
Modifier
Description
GY
An item or service is that statutorily excluded
QL
The patient is pronounced dead after the ambulance is called but before transport.
TQ
Basic life support by a volunteer ambulance provider
Medicare Non-Covered Transportation Modifiers
The MCO shall require the following modifiers to be used when billing for transports that are non-covered services
by Medicare. These modifiers may be used ONLY with procedure codes A0425-A0429 and A0433-A0434 to allow
the claim to bypass the Medicare edit and process as a Medicaid claim. These modifiers will bypass the Medicare
edit for non-emergency transports ONLY and should be billed as non-emergency.
Modifier
Description
DD
Clinic/Free-standing Facility to Clinic/Free-standing Facility
DE
Clinic/Free-standing Facility to Nursing Home
DP
Clinic/Free-standing Facility to Physician
DR
Clinic/Free-standing Facility to Residence
ED
Nursing Home to Clinic/Free-standing Facility
EP
Nursing Home to Physician
ER
Nursing Home to Residence
HP
Hospital to Physician
NP
Skilled Nursing Facility to Physician
PD
Physician to Clinic/Free-standing Facility
PE
Physician to Nursing Home
PN
Physician to Skilled Nursing Facility
PP
Physician to Physician
PR
Physician to Residence
RD
Residence to Clinic/Free-standing Facility
RE
Residence to Nursing Home
RP
Residence to Physician
Encounter Submissions
The MCO shall submit encounters in compliance with the contract and the MCO System Companion Guide.
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Record Retention
All documentation, data, and/or records of the MCO and transportation broker related to the provision of medical
transportation services shall be retained for at least ten years, or longer if those records are subject to review,
audit, or investigation or subject to an administrative or judicial action brought by or on behalf of the state or
federal government. Under no circumstances shall such records be destroyed or disposed of, even after the
expiration of the mandatory ten-year retention period, without the express prior written permission of LDH.
PERSONAL CARE SERVICES
The MCO shall comply with the Personal Care Services Provider Manual chapter of the Medicaid Services Manual
and the additional requirements below.
Electronic Visit Verification for EPSDT PCS and Behavioral
Health PCS
The Louisiana Service Reporting Systems (LaSRS) is LDH’s electronic visit verification (EVV) system for providers of
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) personal care services (PCS) and behavioral
health personal care services. Utilization of an EVV system is a federal requirement that applies to all managed
care PCS providers.
In accordance with the 21st Century Cures Act, LDH collects the following identifiable information for Home and
Community-Based Services (HCBS) waiver and Louisiana Medicaid State Plan services through LaSRS:
The type of service performed;
The enrollee receiving the service;
The date of the service;
The location of service delivery;
The individual providing the service; and
The time the service begins and ends.
LaSRS does not “track” direct service workers—it only collects the location of service delivery at the time of clock-
in and clock-out. LaSRS can be accessed by devices with internet connectivity (e.g., computer, smartphone, tablet).
When a worker “clocks in” or “clocks out”, the system collects the location of the device being used at that time,
as well as the time, date, individual providing the service, and the individual receiving the service. The intent of
this system is to ensure that enrollees receive services authorized in their plans of care, reduce inappropriate
billing/payment, safeguard against fraud, replace paper timesheets, and improve program oversight.
The MCO must require its PCS providers to use LaSRS. The MCO must withhold or deny reimbursement for services
if a PCS provider fails to use the EVV system as directed by LDH.
PHARMACY
The MCO shall cover all medically necessary prescription medicines on the Covered Drug List (CDL).
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The MCO shall not cover the following excluded drugs:
Agents when used for anorexia, weight loss, or weight gain, except orlistat.
Agents when used to promote fertility, except vaginal progesterone when used for high-risk pregnancy to
prevent premature births.
Agents when used for symptomatic relief of cough and colds, except for antihistamine and
antihistamine/decongestant combination products.
The MCO shall cover the following drugs, with restrictions:
Agents used for cosmetic purposes or hair growth only when medical necessity has been determined.
Select drugs for erectile dysfunction, except when used for the treatment of conditions or indications
other than erectile dysfunction as approved by the FDA.
The MCO shall notify LDH prior to implementing or changing any prescription limits. The MCO shall cover a
minimum of four prescriptions per calendar month if prescribed for the enrollee. However, it may not enact
prescription limits more stringent than those in the Louisiana Medicaid State Plan. If prescription limits are
enacted, the MCO shall have Point of Sale (POS) override capabilities when a greater number of prescriptions per
calendar month are determined to be medically necessary by the prescriber.
Except for the use of LDH-approved generic drug substitution of branded drugs, under no circumstances shall the
MCO permit the therapeutic substitution of a prescribed drug without a prescriber's authorization.
Covered Drug List
In accordance with 42 C.F.R. § 438.3, the MCO shall maintain a Covered Drug List (CDL) which includes all
outpatient drugs for which the manufacturer has entered into a federal rebate agreement and meet the standards
in Section 1927 of the Social Security Act.
The CDL shall include all drugs deemed medically necessary for enrollees under the age of 21.
The CDL shall exclude only those drugs or drug categories permitted for exclusion under Section 1927(d) of the
Social Security Act, with exceptions listed in the State Plan. MCOs may cover compounded drugs, diabetic supplies,
and rebate eligible OTCs as a regular pharmacy benefit (not value added). MCOs may cover additional drugs as a
value added benefit. MCOs shall cover, at a minimum, all vaccines and administration covered by FFS for adults
and make them payable in the same program types.
The CDL shall be updated at least weekly using a national drug database.
When drugs (OTC or legend) are being covered as a pharmacy benefit and offered as a value-added benefit,
pharmacy encounters shall indicate such in the Character 1: Submission type (Q, F, or V) of the 4-character prefix
on the ICN of the Rx encounter.
The MCO may apply Point of Sale safety and utilization edits that align with FDA indications.
Self-administered drugs dispensed by a pharmacy, including specialty pharmacies, shall be covered as a pharmacy
benefit unless otherwise approved by LDH.
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The medications listed in the U.S. Preventive Services Task Force (USPSTF) A and B Recommendations shall be
payable as a pharmacy benefit and exempt from copay. Corresponding age limits may be applied.
Physician-administered drugs that are not listed on the FFS fee schedule but for which the manufacturer has
signed a federal rebate agreement shall be covered as either a pharmacy benefit or a medical benefit. If the
physician administered drug is not on the FFS fee schedule, but the MCO covers as a medical benefit, then
reimbursement shall be set as a minimum by the current FFS reimbursement methodology in the State Plan.
Preferred Drug List
A subset of the CDL shall be the Preferred Drug List (PDL). The PDL is established by LDH and indicates the preferred
and non-preferred status of covered drugs.
The PDL shall be maintained by LDH and made available on the LDH website [link
]. The MCO shall make the PDL
available to its providers and enrollees through electronic prescribing tools and a static link on the MCO website
to the PDL maintained on the LDH website.
LDH shall provide the MCO with a list of drugs included on the PDL by NDC number after each FFS Pharmaceutical
and Therapeutics Committee (P&T) meeting and upon the Secretary’s approval of P&T recommendations.
Changes shall be implemented January 1 and July 1 after the P&T meeting, unless otherwise directed by LDH. LDH
shall provide the MCO at least 30 days written notice prior to the implementation date of any changes to the list
of drugs included on the PDL.
LDH shall monitor the rate of MCO compliance with the PDL. Compliance rate shall be defined as the number of
preferred prescriptions paid (drugs classified with PA Indicators 1 & 3) divided by total prescriptions paid for drugs
in therapeutic classes listed on the PDL (drugs classified with PA Indicators 1-4). The MCO shall achieve at least a
92% overall compliance rate and at least a 92% compliance rate for each medication on the brand-over-generic
list provided by LDH (calculated as brand/(brand + generic)). The PDL compliance rate shall be calculated at the
sole determination of LDH. Failure to meet both of these standards may result in monetary penalties as set forth
in the Contract.
New drugs entering the marketplace in the PDL therapeutic classes shall be added as non-preferred until P&T
reviews the drug, unless otherwise directed by LDH.
If a branded product with generic available is preferred on the PDL, the MCO shall not require the prescriber to
indicate in writing that the branded product is medically necessary. The MCO shall reimburse for a brand name
drug at a brand reimbursement when the brand drug is preferred. POS denial messaging for the generic entity
shall indicate that the brand name is preferred.
The fiscal intermediary will post weekly drug file data for the MCO. The MCO shall have three business days after
receipt of file to download and implement drug prior authorization status, for drugs covered as an outpatient
pharmacy benefit.
There shall be a mandatory generic substitution for all drugs, when a generic is available, unless the brand is
justified with applicable dispense as written (DAW) codes or the brand is preferred.
Claims for multi-source “Brand Name Products” that are not included in the PDL/NPDL process (drugs not listed
on the Preferred Drug List on the static link), will not be subject to prior authorization. Since the manufacturers
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of these brand name products have signed the federal rebate agreement, these drugs must have a potential
payable status. In consideration of the mandatory generic substitution, we are requiring the MCO/PBMs to allow
DAW codes “1”, “5” and “9” for brand name processing. We would expect these codes to accommodate the filling
of a brand name product without use of prior authorization. Preferred brand over generic drugs should process
with DAW 9. Brand name medically necessary from prescriber should process with a DAW 1. Denials of brand
drugs (unless the Brand is a preferred drug—in or out of the process) should deny with an error code stating
“generic substitution required”, mapped to NCPDP 22 (M/I Dispense as written (DAW)/Product selection code).
Manufacturer-Derived Revenue
The MCO shall not negotiate, pursue collection of, or collect Manufacturer-Derived Revenue for prescribed drugs.
The MCO shall diligently and in good faith negotiate, maximize, and pursue collection of all Manufacturer-Derived
Revenue for diabetic supplies on behalf of LDH.
The MCO shall report all Manufacturer-Derived Revenue the MCO receives, including any future Manufacturer-
Derived Revenue, related to any covered drug or diabetic supply provided under the Contract, according to the
Financial Reporting Guide. This provision survives termination of the contract between LDH and the MCO. The
MCO shall report all Manufacturer-Derived Revenue received on claims incurred prior to the termination of the
contract until one hundred percent (100 percent) of earned Manufacturer-Derived Revenues specific to the
contract between LDH and the MCO are paid.
Within ten (10) business days of LDH’s request, the MCO shall provide LDH with unredacted copies of or access to
all books, records, and Manufacturer-Derived Revenue agreements with pharmaceutical and diabetic supply
manufacturers, intermediaries, subcontractors, wholesalers, or other third parties related to the Contract. This
provision applies to the MCO as well as all subcontractors. All such information shall be kept confidential by LDH
and shall be exempt from disclosure under the Louisiana Public Records Law.
Within ten (10) business days of LDH’s request, the MCO shall provide LDH an itemized report of all Manufacturer-
Derived Revenue amounts received by the MCO and its subcontractors, if applicable, within a specified time
period. This report must itemize Manufacturer-Derived Revenue by National Drug Code number and
manufacturer, indicate amounts paid to the MCO, and indicate the time frames when the Manufacturer-Derived
Revenue was received by the MCO or its subcontractors. The report must also indicate when the Manufacturer-
Derived Revenue was paid to the MCO by the PBM, if applicable.
Hepatitis C Project
The MCO shall follow the PDL preferred/non-preferred status and criteria. The MCO PBM shall program denials
of 340B claims for all Hepatitis C direct acting anti-viral (DAA) agents. The denials shall be based on the 340B
pharmacy list provided by LDH quarterly.
Behavioral Health Specific Pharmacy Policies and Procedures
The MCO shall develop LDH approved policies and procedures that meet or exceed the following requirements:
The MCO or its subcontractor(s) shall contract with the psychiatric facilities and residential substance use
facilities so that the plans are notified upon patient admission and upon patient planned discharge from
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the psychiatric facility or residential substance use facilities. Prior to discharge the MCO shall be informed
of the enrollee’s discharge medications. The MCO shall then be responsible to override or allow all
behavioral health discharge medications to be dispensed by overriding prior authorization restrictions for
a sixty (60) day period. This includes, but is not limited to, naloxone, Suboxone, and long-acting injectable
anti-psychotics.
If the MCO is not notified prior to the discharge and the enrollee presents at the pharmacy with a
medication issued at the time of discharge, the MCO shall provide a prior authorization override for a sixty
(60) day period from the date of discharge as long as the enrollee presents the prescription within sixty
(60) days of being discharged from a psychiatric and/or residential substance use facility.
The MCO shall have a specific Suboxone, Subutex and methadone management program and approach,
which shall be approved by LDH. The policy and procedure must be in accordance with current state and
federal statutes in collaboration with the State Opioid Treatment Authority/LDH.
The MCO shall have a LDH approved pharmacy management program and approach to stimulant
prescribing for children under age 6, and persons age 18 or older.
The MCO shall have a LDH approved program and approach for the prescribing of antipsychotic
medications to persons under 18 years of age.
The MCO shall use encounter, beneficiary, and prescription data to compare Medicaid physician, medical
psychologist or psychiatric specialist APRN’s prescribing practices to nationally recognized, standardized
guidelines, including but not limited to, American Psychiatric Association Guidelines, American Academy
of Pediatrics Guidelines, American Academy of Child, and Adolescent Psychiatry Practice Parameters.
Brand Name and Generic Drugs
Claims for multi-source “Brand Name Products” that are not included in the PDL/NPDL process (i.e., drugs not
listed on the Preferred Drug List on the static link), shall not be subject to prior authorization. Since the
manufacturers of these brand name products have signed the federal rebate agreement, these drugs must have
a potential payable status. In consideration of the mandatory generic substitution, LDH requires the MCOs/PBMs
to allow dispense as written (DAW) codes “1”, “5”, and “9” for brand name processing. LDH expects the following
codes to accommodate the filling of a brand name product without use of prior authorization:
DAW “1”: Brand name medically necessary from prescriber.
DAW “5”: Substitution allowed-brand drug dispensed as a generic (should be allowed when the brand
drug is less expensive for 340B providers).
DAW “9”: Preferred brand over generic drugs.
Denials of brand drugs (unless the brand is a preferred drug—in or out of the process) should deny with an error
code stating “generic substitution required”, mapped to NCPDP 22 (M/I Dispense as written (DAW)/Product
selection code).
Drug Utilization Review Program
The MCO shall maintain a Drug Utilization Review (DUR) program in accordance with the Contract and the CMS
Managed Care Final Rule (CMS-2390-F). The Prospective DUR Program, Retrospective DUR Program, and
Educational DUR Program standards implemented by the MCO shall be consistent with the standards established
by LDH in the Contract. The MCOs and Medicaid FFS will implement new and revised DUR criteria as voted on by
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the Medicaid DUR Board. LDH will send the MCO the approved new and revised MCO-specific DUR criteria, and
the MCO shall implement within the time period established by LDH. DUR initiatives directed by LDH shall be
implemented as directed or with written LDH approval of alternative programming reaching the same outcomes.
DUR initiatives not or incorrectly implemented may result in monetary penalties.
Any revisions to the MCO’s DUR policy, procedures, or standards shall be approved by LDH prior to
implementation. At a minimum, the MCO DUR programs shall include all Medicaid DUR Board initiatives and shall
submit any new initiatives to LDH that it would like to include on the Medicaid DUR Board agenda at least 45 days
in advance of the DUR Board meeting.
The MCO shall provide a detailed description of its DUR program annually to LDH to comply with CMS DUR annual
reporting requirements as per the Managed Care Final Rule. The annual report to the state will be due six weeks
after LDH sends the CMS template to the MCOs. The MCO shall be responsible for developing responses to any
questions posed by CMS on the annual report and for coordinating its response through LDH. MCOs are required
to program their claims processing systems to capture claim level data that is required by CMS for incorporation
into the DUR Annual Report.
The MCO DUR program shall contain the following components:
Prospective DUR Program
The MCO shall provide for a review of drug therapy at Point of Sale (POS) before each prescription is given to the
enrollee. Screening should be performed for potential drug problems due to therapeutic duplication, drug-disease
contraindications, drug-drug interactions, duration of therapy, and clinical misuse. The following parameters
should be screened at POS. Inappropriate therapy should trigger edits and each edit should have its own separate
denial code and description including, but not limited to: early refill, duration of therapy, therapeutic duplication,
pregnancy precaution, quantity limit (excluding opioids), quantity limit for long-acting opioids, quantity limit for
short-acting opioids, diagnosis code required on selected agents, drug interactions, age limit, and dose limits.
Reporting capabilities shall exist for these denial codes. The MCOs shall align their coding of NCPDP compliant POS
edits and overrides with LDH. Prior authorization is not an acceptable method to override certain POS edits.
Pharmacy claims processing shall be capable of capturing diagnosis codes at the POS and utilizing codes in the
adjudication process at POS. Denial of pharmacy claims could be triggered by an inappropriate diagnosis code or
the absence of a diagnosis code.
The MCO shall allow pharmacist overrides on selected POS denials as instructed by LDH. Pharmacist overrides
shall utilize NCPDP established standards.
The MCO should ensure the pharmacist offers to counsel the patient or caregiver. A log of receipt of prescription
and the offer to counsel by the pharmacist shall be incorporated into MCO policy.
The MCOs shall follow prospective safety edits for opioids including early, duplicate and quantity limits, as
specified by the state, to comply with the SUPPORT Act.
The MCOs shall follow maximum daily morphine milligram equivalents (MME) prospective safety edits, as
specified by the state, to comply with the SUPPORT Act.
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The MCOs shall follow the State’s clinical authorization criteria for monitoring and managing the appropriate use
of antipsychotic medications by children enrolled under the State plan, in order to comply with the SUPPORT Act.
Early refill edit on controlled drugs shall be set at 90% used.
Each inappropriate therapy edit identified through the Prospective DUR Program shall be coded with an individual
denial description, which shall be reported separately.
Some DUR prospective criteria will allow for a soft edit or a pharmacist override. MCOs shall align National Council
for Prescription Drug Programs (NCPDP) compliant POS edits and overrides. When the pharmacist receives a
prospective DUR alert message that requires a pharmacist’s review, the MCO POS system shall have the capability
to allow the pharmacist to override the alert using the appropriate NCPDP “conflict, intervention and outcome”
codes or other NCPDP compliant PA/MC
9
override. POS overrides shall be implemented upon LDH direction. The
MCO shall identify the top 10 pharmacies that have the most edit overrides and report them on the revised
monthly DUR report (RX162).
Denial of pharmacy claims could be triggered by an inappropriate diagnosis code or the absence of a diagnosis
code, depending on the Medicaid DUR Board approved criteria. Diagnosis codes shall be supplied by the prescriber
on the prescription or transmitted verbally from the prescriber’s office to the pharmacist. The pharmacist shall
enter the diagnosis code at POS in NCPDP field 424-DO (diagnosis code).
MCO reporting, in accordance with the new CMS Managed Care Final Rule, shall include but not be limited to, the
following:
Top drug claims data reviewed by the DUR Board (See Tables in MCO DUR Annual Report [link
]):
1. Top 10 prior authorization (PA) requests by drug name;
2. Top 10 PA requests by drug class;
3. Top five claim denial reasons other than eligibility (e.g., quantity limits, early refill, PA, therapeutic
duplications, age limits);
4. Top 10 drug names by amount paid;
5. From data in number 4, a determination of the percentage of total drug expenditures;
6. Top 10 drug names by claim count; and
7. From data in number 6, a determination of the percentage of total claims represented by the top 10 drugs.
The MCO shall comply with all final reporting requirements and/or templates produced by CMS.
Retrospective DUR Program
The MCO, in conjunction with LDH, shall provide for the ongoing periodic examination of claims data to identify
patterns of gross overuse, abuse, potential fraud, and inappropriate or medically unnecessary care among
prescribers, pharmacists, or enrollees.
9
Indicates that the use of the drug may be inappropriate in light of a specific medical condition that the patient has.
Information about the specific medical condition was provided by the prescriber, patient, or pharmacist.
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Claims review must be assessed against predetermined standards while monitoring for therapeutic
appropriateness. Prescribers and pharmacists should be contacted via an electronic portal or other electronic
means if possible. Facsimile and mail will suffice in some instances.
Retrospective DUR initiatives shall be implemented monthly as directed by LDH. The MCOs shall follow
retrospective automated claim reviews of opioid and benzodiazepines concurrent fill reviews and opioid and
antipsychotic concurrent fill reviews on an annual basis, in order to comply with the SUPPORT Act. Additional
retrospective DUR initiatives may be implemented by the MCO when previously approved by LDH.
At a minimum, the MCO shall implement all of the DUR Board approved retrospective initiatives. An
implementation timeline for retrospective interventions will be coordinated through LDH. Retrospective
interventions are defined as communication from the MCO through intervention letters to the provider when DUR
criteria are met.
Intervention letters, including enrollee profiles, shall be sent to selected prescribers and/or pharmacy providers
and include the following:
Cover sheet (template will be provided by LDH);
Response sheet (template will be provided by LDH);
Additional enclosures, if applicable (examples include recommendations and supportive clinical guidelines
if not included in cover sheet); and
Enrollee profile with at least nine months of historical data. In order to display drug utilization patterns,
the MCO or its PBM shall generate enrollee profiles, which shall be approved by LDH and sent to the
prescriber and/or pharmacy provider. Enrollee profiles shall be composed of the following elements:
o Enrollee information – name, Medicaid ID, date of birth, and gender – should be included in the
header on every page;
o Prescription claim information, including drug name; National Drug Code (NDC); prescription
number; diagnosis (if provided); date of service; quantity dispensed; days’ supply; pharmacy
information such as name, address, and National Provider Identifier (NPI) number; and prescriber
information (name, address, NPI);
o Physician administered drugs (currently optional); and
o Exception criteria and description should be displayed at the beginning of the enrollee profile
(e.g., 1-Famotidine: exceeds maximum recommended dose (80 mg/day); 2-Contraindication:
dorzolamide/timolol ophthalmic for patient with asthma; 3-Possibility of patient non-compliance
with anti-diabetes therapy).
To determine if intervention letters are necessary, the MCO shall have a clinician, or a team of clinicians, evaluate
the enrollee profile before sending the intervention letter. Clinicians shall be pharmacists, nurses, or physicians.
The clinician must be familiar with current clinical guidelines. The purpose is to send only meaningful information
to the prescriber/pharmacist that will enable them to improve the enrollee’s care.
The MCO shall track and report prescriber/pharmacist responses to intervention letters through standing
reporting established by LDH. Reporting shall include, but not be limited to, the following for the DUR annual
report to CMS:
Retrospective DUR Educational Outreach Summary. Rank of the top 10 interventions: number of hits
(numerator)/number of claims (denominator). This is a year-end summary report on RetroDUR screening
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and educational interventions. The year-end summary reports should be limited to the top 10 problems
with the largest number of exceptions including the results of RetroDUR screening and interventions.
Summary of Medicaid DUR Board Activities. LDH or its fiscal intermediary will supply this information to
the MCO for inclusion in its CMS annual report. Separately, the MCO shall include additional MCO-initiated
activities which have been approved by LDH.
Generic Drug Substitution Policies. The description of policies that may affect generic utilization
percentage.
Generic Drug Utilization Data. This includes the number of generic claims, total number of claims, and
generic utilization percentage. CMS has developed an extract file from the Medicaid Drug Rebate Program
Drug Product Data File identifying each NDC along with sourcing status of each drug: S (Single Source), N
(Non-Innovator Multiple-Source), or I (Innovator Multiple-Source). This file will be made available by CMS
to facilitate consistent reporting across states with this data request.
Innovative Practices. Describe in detailed narrative form any innovative practices that are believed to have
improved the administration of the MCO’s DUR program, the appropriateness of prescription drug use,
and/or have helped to control costs (i.e., disease management, academic detailing, automated prior
authorizations, continuing education programs).
E-Prescribing Activity Summary. Describe all development and implementation plans/accomplishments in
the area of e-prescribing.
Executive Summary.
Within the LDH standing report, retrospective intervention reporting shall also include but not be limited to the
following for the Medicaid DUR Board (six months after the intervention letter is sent):
Number of enrollee profiles reviewed. This is the number of enrollee profiles reviewed by the clinician.
One enrollee profile is one enrollee; one enrollee profile can have more than one intervention.
Number of enrollee profiles with intervention letters issued. More than one provider can get a letter for
the same enrollee; one letter can address more than one intervention.
Number of responses and response rate.
Educational DUR Program
The MCO shall provide active and ongoing educational outreach programs to educate and inform prescribers and
pharmacists on common drug therapy programs with the aim of improving prescribing and/or dispensing
practices. The frequency of patterns of abuse and gross overutilization or inappropriate or unnecessary care
among prescribers, pharmacists and recipients should be identified.
MCOs should educate prescribers, pharmacists, and enrollees on therapeutic appropriateness when
overutilization or underutilization occurs. LDH expects the MCOs to use current clinical guidelines and national
recommendations to alert prescribers and pharmacists of pertinent clinical data. Clinical outcomes shall be
monitored by the MCO and reported to LDH on a periodic basis established by the Department.
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Lock-In Program
General Requirements
Lock-In shall be utilized when LDH or the MCO finds that an enrollee has utilized Medicaid pharmacy services at a
frequency or amount that is not medically necessary, as determined in accordance with utilization guidelines. The
enrollee may be restricted for a reasonable period of time to obtain Medicaid pharmacy services from designated
providers only in accordance with 42 C.F.R. §431.54(e).
Two types of Lock-In shall be utilized. An enrollee may be selected for Pharmacy-Prescriber Lock-In enrollment,
where the enrollee will be allowed one primary care provider and specialist(s) if needed, and a single pharmacy
provider and specialty pharmacy if needed; or Pharmacy-only Lock-In where the enrollee is asked to choose only
one pharmacy provider and specialty pharmacy if needed to fill all of his/her prescriptions. Providers shall be fully
enrolled in the FFS Medicaid program. The lock-in mechanism does not prohibit the enrollee from receiving
services from providers who offer services other than prescriber and pharmacy benefits.
The MCO shall implement and maintain a statewide Pharmacy-only and a Pharmacy-Prescriber Lock-In program,
in which the MCO will identify enrollees who are using pharmacy services at a frequency or amount that is
excessive or not medically necessary, as determined in accordance with utilization guidelines established by LDH,
in conformance with 42 C.F.R. §431.54(e). Lock-In shall be executed as specified in this manual.
Enrollees may change lock-in providers every year without cause. With good cause, they may change lock-in
providers only with the MCO’s approval. Enrollees may change providers for the following “good cause” reasons:
An enrollee relocates;
An enrollee’s primary diagnosis changes;
The lock-in provider(s) request(s) that the enrollee be transferred; or
The lock-in provider(s) stop(s) participating in the Medicaid program and does not accept Medicaid as
reimbursement for services.
The PBM shall have Point of Sale denials to restrict enrollees to the lock-in pharmacy and/or prescriber(s).
When the lock-in termination period has expired, the enrollee shall be reevaluated to determine future lock-in
status.
Regardless of the enrollee’s movement between MCOs, the enrollee shall remain in lock-in status until the
established termination lock-in period has expired.
In case of an emergency, the MCOs and/or PBM shall allow an emergency supply of medication to be filled by a
pharmacy other than the lock-in pharmacy to ensure access to necessary medication. Emergency fills may be
subject to audit.
Enrollee Selection
On a periodic basis, the fiscal intermediary will select and generate a potential enrollee list for the lock-in program
based on established criteria. The MCO shall notify potential lock-in enrollees of its intent to lock enrollees into a
limited number of providers. The MCO shall grant appeal rights to the enrollees.
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Each MCO may lock-in additional enrollees based on their own independent review, clinical criteria, or referral.
The MCO shall conduct a second review to identify any enrollee that would not benefit from the program due to
complex drug therapy or other case management needs.
LDH shall be notified of those recommendations.
Lock-In Letters
The MCO shall utilize the LDH lock-in letter templates located at https://ldh.la.gov/page/pharmacy-templates-for-
managed-care-organizations and be responsible for the following:
Notifying the enrollee, chosen pharmacy provider, and/or chosen prescribing provider of the proposed
lock-in status;
Giving the enrollee notice and an opportunity for a hearing, in accordance with procedures established
by LDH and the CFR, before imposing the restrictions;
Ensuring the enrollee has reasonable access, taking into account geographical location and travel time,
to quality Medicaid services;
Sending the initial enrollee notification letter no later than sixty (60) days prior to the effective lock-in
date. Letters shall include lock-in period of restriction (effective and termination dates), pharmacy
choice selection, and details on the enrollee’s appeal rights, and pharmacy and/or prescribing provider
selection; and
Restricting the enrollee as instructed no later than ninety (90) calendar days after receiving the enrollee
list, as long as the enrollee does not file an appeal.
Medication Therapy Management
General Requirements
The MCO shall have established a medication therapy management (MTM) program that:
Is comprehensive and patient-centered;
Is designed to increase medication adherence;
Is designed to ensure that medications are appropriately used to optimize therapeutic outcomes through
improved medication use;
Is designed to reduce the risk of adverse events from medication therapy;
May be administered by a pharmacist or other qualified providers, such as physicians, nurse practitioners,
physician assistants, or nurses;
Shall be developed in cooperation with licensed and practicing pharmacists and physicians; and
Shall include coordination between the MCO, the enrollee, the pharmacist and the prescriber using
various means of communication.
To assess the enrollee’s medication therapy, the MTM program shall include an interactive comprehensive
medication review (CMR), which includes enrollee discussion and prescriber intervention if needed. This results
in the creation of a written summary and is followed by frequent monitoring with further interventions as needed.
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The MCO shall ensure that all requirements are met regardless of whether the MCO utilizes a contractor for MTM
services. The MCO and its contractor, if applicable, shall not limit the MTM services provided for enrollees meeting
MTM criteria. MTM criteria must be approved by LDH pharmacy staff. MTM shall be executed as specified herein
and as directed by LDH.
Enrollment
The MCO shall enroll targeted enrollees in an opt-out method of enrollment only. This means enrollees may
choose to opt-out of the program if desired at any time.
The MCO shall auto-enroll the targeted enrollees each year when they meet the eligibility criteria, and they are
considered enrolled in the MTM program unless the enrollee declines enrollment. The enrolled may refuse or
decline individual services without having to disenroll from the MTM program.
Targeted Enrollees
The MTM program may include enrollees with multiple chronic diseases or any specific chronic disease. If the
MTM program is designed to target individual specific chronic diseases, then the program shall include at least
three of the following:
Behavioral health (such as Alzheimer’s disease, bipolar disorder, depression, schizophrenia, or other
chronic/disabling mental health conditions);
Bone disease-arthritis (such as osteoporosis, osteoarthritis, or rheumatoid arthritis);
Cardiovascular disease (such as dyslipidemia, heart failure, or hypertension);
Diabetes;
End-stage renal disease (ESRD);
Hepatitis C infection;
Respiratory disease (such as asthma, chronic obstructive pulmonary disease (COPD), or chronic lung
disorders); and
Substance use disorder.
The MCO should also offer MTM services to an expanded population of enrollees who do not meet the eligibility
criteria but would benefit from MTM services. The MCO shall also leverage effective MTM to improve safety (e.g.,
increase adherence to medications, reduce the use of high-risk medications, and address issues of overutilization).
Required MTM Services
The MCO shall offer a minimum level of MTM services to each enrollee in the program that includes all of the
following:
Interventions for both enrollees and prescribers, as needed; and
An annual Comprehensive Medication Review (CMR) with written summaries created in a standardized
format approved by LDH; and
Targeted Medication Reviews (TMRs), when needed, with follow-up interventions when necessary.
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Comprehensive Medication Review
Comprehensive Medication Review (CMR) is a systematic process of:
Collecting patient-specific information;
Assessing medication therapies to identify medication-related problems;
Developing a prioritized list of medication-related problems; and
Creating a plan to resolve them with the patient, caregiver and/or prescriber.
The MCO shall offer a CMR to all enrollees in the MTM program at least annually.
The MCO shall offer to provide a CMR to newly targeted enrollees as soon as possible after enrollment into the
MTM program, but no later than 60 days after being enrolled in the MTM program.
The enrollee’s CMR shall be conducted using an interactive, person-to-person review (including prescriptions,
over-the-counter medications, herbal therapies and dietary supplements) performed by a pharmacist or other
qualified provider, and may result in a recommended medication action plan.
A written summary of the results of the review shall be provided to the targeted individual(s) in a standardized
format approved by LDH and shall include the following:
Any concerns the enrollee may have regarding their drug therapy;
Purpose and instructions for use of the enrollee’s medications; and
Personal medication list (including prescription, non-prescription drugs, and supplements) which will aid
in assessing medication therapy and engaging the enrollee in management of his or her drug therapy.
The MCO shall encourage enrollees to take their action plan and personal medication list from their CMR to any
medical encounter (e.g., physician visit, pharmacy, or hospital admission). This summary shall serve as a valuable
tool to share information across providers and help reduce duplicate therapy and drug-drug interactions.
Targeted Medication Review
The MCO shall perform Targeted Medication Reviews (TMRs) when needed to address potential or specific
medication-related problems, to assess any transition of care the enrollee may have experienced, or to monitor
new, unresolved, or continued medication therapies. The findings of the TMR shall then be reviewed to determine
if a follow-up intervention is needed for the enrollee or the prescriber. The MCO may determine how to tailor the
follow-up intervention based on the specific needs or medication use issues of the enrollee. For example, these
interventions may be person-to-person or telephonic.
Outcomes Measurement
The MCO shall have a process in place to measure, analyze, and report the outcomes of their MTM program. This
process shall include whether the goals of therapy have been reached and shall capture drug therapy
recommendations and resolutions made as a result of MTM recommendations. A recommendation is defined as
a suggestion to take a specific course of action related to the enrollee’s drug therapy. Examples of drug therapy
problem recommendations made as a result of MTM services and recommendations include, but are not limited
to:
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Needs additional therapy;
Unnecessary drug therapy;
Dosage too high;
Dosage too low;
Adverse drug reaction;
Medication non-adherence;
Initiate drug;
Change drug (such as product in different therapeutic class, dose, dosage form, quantity, or interval);
Discontinue or substitute drug (such as discontinue drug, generic substitution, therapeutic substitution,
or formulary substitution); or
Medication adherence.
Quarterly Reporting Requirements
Reporting is an important factor in determining the effectiveness of an MTM program. The MCO shall document
interventions, contact attempts, number of enrollees enrolled, and other associated parameters. Report
requirements include, but are not limited to the following:
Enrollee enrollment parameters;
Number of contact encounters and contact-related outcomes;
Number of MTM interventions, both telephonic and face-to-face;
Number of comprehensive medication reviews;
Number of drug therapy problems identified, such as potential drug-drug interactions, adverse events, or
the simplification of a complex regimen with the same therapeutic benefit; and
Number of drug therapy problems resolved, such as modifications to drug dose, form, or frequency or
changes in drug regimen due to identification of potential adverse event or interaction.
If specific disease states are targeted, the MCO shall include the following:
Number of drug-related parameters improved, such as improved adherence in disease-specific
medication regimen, modifications in drug therapy to reflect appropriate current treatment guidelines,
or disease-related laboratory test monitoring;
Percentage of the MCO’s enrollee population with each targeted disease state that received MTM
services; and
An example of a positive outcome demonstrated by MTM interventions for each targeted disease state.
Examples include improvement in blood pressure measurements, A1C levels, LDL levels, etc.
This information shall be submitted to LDH on a quarterly basis, by the 30
th
day of the month following the end of
the reporting period.
Mosquito Repellent Coverage
The MCO shall cover mosquito repellant as a pharmacy benefit to decrease the risk of exposure to the Zika virus.
Coverage must be provided for enrollees who are:
Pregnant; or
Of childbearing age (women and men ages 14-44) who are trying to conceive.
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One bottle of mosquito repellent every rolling 30 days will be allowed. A prescription will be required to cover one
of the following products:
Product Name
Ounces
Bill As
UPC
“NDC”
Cutter Backwoods 25% Spray
6 oz.
170 g
71121962805
71121-0962-80
Cutter Skinsations 7% Spray
6 oz.
177 mL
16500540106
16500-0540-10
OFF! Family Care 15% Spray
2.5 oz.
71 g
46500018428
46500-0710-37
OFF! Deep Woods Dry 25% Spray
4 oz.
113 g
46500717642
46500-0717-64
OFF! Deep Woods 25% Spray
6 oz.
170 g
46500018428
46500-0018-42
OFF! Active 15% Spray
6 oz.
170 g
46500018107
46500-0018-10
Repel Sportsmen 25% Spray
6.5 oz.
184 g
11423941375
11423-0941-37
Repel Sportsmen Max 40% Spray
6.5 oz.
184 g
11423003387
11423-0003-38
Natrapel 20% Picaridin
5 oz.
177 mL
44224068781
44224-0068-78
Sawyer Insect Repellent 20% Picaridin
4 oz.
118 mL
50716005448
50716-0005-44
Opioid Prescription Policy
The MCO shall have an opioid prescription policy that includes the following:
Acute Pain
o 7-day quantity limit for opioid-naïve enrollees or Morphine Milligram Equivalent (MME) limit of
90 milligram per day, whichever is less. Opioid-naïve enrollees are enrollees with no opioid claims
in the most current 90 days.
Chronic Pain
o Morphine Milligram Equivalent (MME) limit of 90 milligram per day for all opioid prescriptions.
Exemptions that bypass opioid quantity limits shall include:
DIAGNOSIS DESCRIPTION
CODE
Cancer
C00.* – C96.*
Palliative Care
Z51.5
Burn of second or third degree of head, face and neck
T20.2* – T20.3*
Corrosion of second or third degree of head, face and neck
T20.6* – T20.7*
Burn of second or third degree of trunk
T21.2* – T21.3*
Corrosion of second or third degree of trunk
T21.6* – T21.7*
Burn of second or third degree of shoulder and upper limb, except wrist and hand
T22.2* – T22.3*
Corrosion of second or third degree of shoulder and upper limb, except wrist and hand
T22.6* – T22.7*
Burn of second or third degree of wrist and hand
T23.2* – T23.3*
Corrosion of second or third degree of wrist and hand
T23.6* – T23.7*
Burn of second or third degree of lower limb, except ankle and foot
T24.2* – T24.3*
Corrosion of second or third degree of lower limb, except ankle and foot
T24.6* – T24.7*
Burn of second or third degree of ankle and foot
T25.2* – T25.3*
Corrosion of second or third degree of ankle and foot
T25.6* – T25.7*
Hb-SS disease with crisis
D57.0
Hb-SS disease with crisis, unspecified
D57.00
Hb-SS disease with acute chest syndrome
D57.01
Hb-SS disease with splenic sequestration
D57.02
Sickle-cell/Hb-C disease with crisis
D57.21
Sickle-cell/Hb-C disease with acute chest syndrome
D57.211
Sickle-cell/Hb-C disease with splenic sequestration
D57.212
Sickle-cell/Hb-C disease with crisis, unspecified
D57.219
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Sickle-cell thalassemia with crisis
D57.41
Sickle-cell thalassemia with acute chest syndrome
D57.411
Sickle-cell thalassemia with splenic sequestration
D57.412
Sickle-cell thalassemia with crisis, unspecified
D57.419
Other sickle-cell disorders with crisis
D57.81
Other sickle-cell disorders with acute chest syndrome
D57.811
Other sickle-cell disorders with splenic sequestration
D57.812
Other sickle-cell disorders with crisis, unspecified
D57.819
Clotting Factor
The MCO shall follow the FFS reimbursement methodology for clotting factor products in the Louisiana Medicaid
State Plan, effective October 1, 2023, contingent on CMS approval and as directed by LDH. Clotting factor products
will be identified by LDH. Clotting factor products administered in an outpatient setting shall only be reimbursed
as a pharmacy benefit, not as a medical/professional benefit.
Pharmacy Copayment
Copayment Threshold
The MCO must have a Point of Sale edit that will apply a per-enrollee maximum monthly copayment and turn off
cost sharing when maximum copayments are met.
All copay exemptions shall be applied. The fiscal intermediary provides a monthly report to the MCOs with the
per-enrollee maximum monthly copayment. This will eliminate all of the risk for enrollees to exceed the 5 percent
aggregate family limit.
Exemptions for Preventive Medications
To be in compliance with the Affordable Care Act (ACA) requirements related to coverage of preventive
medications, medications listed in the U.S. Preventive Services Task Force (USPSTF) A and B Recommendations
should be reimbursable and exempt from pharmacy copayments. Corresponding age limits may be applied.
Prior Authorization
MCO prior authorization (PA) criteria shall align with FFS for drugs on the Single PDL that were filled in an
outpatient pharmacy setting. LDH intends to align FFS and MCO criteria for drugs not on the Single PDL over time
through the DUR board. The MCO shall have input on PA criteria development and representation on the DUR
board. The MCO shall have a PA process that complies with 42 C.F.R. § 438.3(s)(6) and the following requirements.
The MCO shall allow prescribers, and may allow pharmacies at the MCO’s discretion, to submit PA
requests by phone, fax or an automated process.
The MCO shall provide access to a toll-free call center for prescribers to call to request PA for non-
preferred drugs or drugs that are subject to clinical edits. If the MCO or its pharmacy benefit manager
operates a separate call center for PA requests, it will be subject to the provider call center standards and
monetary penalties set forth in the Contract.
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PA requests shall be approved or denied within 24 hours of receipt, seven days a week. The MCO shall
notify the requesting practitioner of the approval or disapproval of the request within 24 hours. Denials
of prior authorization requests or offering of an alternative medication shall be provided to the prescriber
and enrollee in writing. PA denials may be appealed in accordance with the Contract.
Consistent with the requirements of Section 1927 of the Social Security Act, LDH will hold MCOs to a 99.5%
compliance rate with the 24-hour PA resolution requirement. If an MCO is reporting less than 99.5% compliance
on the RX055 report, justification shall be included with the report in the notes section.
The MCO shall have an automated process that allows the pharmacy to dispense without PA at least a 72-hour
emergency supply of a product or full unbreakable package. At a minimum, the MCO shall allow two emergency
supply fills per prescription. The MCO shall reimburse the pharmacy for both the ingredient and the dispensing
fee for both fills. Emergency fills may be included in a post payment review to identify misuse.
The MCO shall prior authorize drugs with a non-preferred status on the PDL, and shall align its PA criteria with
Louisiana Medicaid pharmacy criteria specified on the PDL.
The MCO shall not prior authorize drugs with a preferred status on the PDL, except to align its PA criteria with FFS
clinical edits.
For self-administered drugs, the MCO shall not prior authorize drugs outside of the PDL process, except to align
its PA criteria with FFS clinical edits or as otherwise directed by LDH.
The MCO may prior authorize drugs when safety and utilization edits are exceeded when approved by LDH, except
for drugs used for the treatment and prevention of HIV/AIDS. Drug utilization edits aligned through DUR initiatives
shall be adhered to; however, safety and utilization edits outside of DUR initiatives may be aligned with FDA
indications.
MCO prior authorization criteria and/or step therapy related to the preference of one agent over another agent
within a therapeutic class listed on the PDL shall not be more restrictive than FFS.
Prior authorization and/or other safety edits are allowed on physician-administered drugs.
If a PA is requested for a narrow therapeutic index (NTI) drug, every effort should be made to verify if the enrollee
is currently on a specific brand/generic, then the PA shall be approved for the corresponding product. NTI drugs
include: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-
Thyroxine, Lithium, Phenytoin, Theophylline, Thyroid, Valproic Acid, and Warfarin.
Prior authorization shall not require more than two failures of preferred products.
The MCO shall override PA for selected drug products or devices at LDH’s discretion, including but not limited to
certain DUR initiatives.
The MCO shall not require PA for drugs with FDA indication for emergency contraception.
The MCO shall not require PA for a dosage change for any medications (including long-acting injectable
antipsychotics) and other medication assisted treatment (including dosages of buprenorphine or
buprenorphine/naloxone) that have been previously authorized and/or approved by the MCO, as long as the
newly prescribed dose is within established FDA guidelines for that medication.
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The MCO shall not penalize the prescriber or enrollee, financially or otherwise, for PA requests or other inquiries
regarding prescribed medications.
An enrollee receiving a prescription drug that was on the PDL and was removed from the PDL or changed from
preferred to non-preferred status shall be allowed to continue to receive that prescription drug for at least 60
days after notification. The MCO shall have 30 days after receipt of the NDC list to send out notifications of
negative changes to prescribers and enrollees. Brand/generic preference changes of the same drug entity do not
constitute a negative PDL change.
When a prescriber is requesting brand name medication that has a generic equivalent, the MCO can encourage a
prescriber to complete the FDA Medwatch form. A Medwatch form shall not be required or considered in the PA
approval/denial determination of a brand drug.
Prior authorization shall not be utilized to prefer a B-rated generic drug over an A-rated generic.
The statewide universal prior authorization form shall be posted and utilized as specified in Act 423 of the 2018
Louisiana Regular Session. In order to obtain necessary information for prior authorization processing, the
following therapeutic drug classes may be considered specialty for prior authorization purposes only: Hepatitis C
Direct Acting Antiviral Agents (as directed by LDH), Spinraza®, Aduhelm®, and Synagis®. MCOs shall utilize the LDH
form and criteria for these specialty classes filled in the outpatient pharmacy setting.
The MCO shall adhere to the provisions of La. R.S. 46:153.3(C)(1) which exempt HIV/AIDS drugs from the prior
authorization process.
340B Policy for Claim Level Indicators
The MCO is required to submit drug-related encounter data to LDH for the purposes of collecting federal Medicaid
rebates. Louisiana Medicaid must prevent duplicate discounts against drug manufacturers when 340B covered
entities dispense drugs purchased through the 340B Discount Program. Federal Medicaid rebates are not allowed
on 340B discount drug utilization.
340B is a federal program administered by the Health Resources and Services Administration (HRSA). HRSA’s
Office of Pharmacy Affairs (OPA) maintains a searchable database of all healthcare providers enrolled as 340B
covered entities. Medicaid and Managed Care Medicaid claims billed by 340B covered entities that self-attest to
HRSA that their Medicaid populations are carved into their 340B programs are removed from Federal Medicaid
Rebate invoicing. This means the provider attests that their Medicaid claims are all 340B discount stock and are
not eligible for Federal Rebate collection. Louisiana Medicaid requires a claim-level indicator be used by the billing
provider in order to denote a drug claim’s status as 340B. Due to the cost to charge methodology, outpatient
hospital claims are excluded from the claim level indicator requirement.
MCOs should include the following requirements in contracts with 340B covered entities.
Pharmacy 340B Drug Claims:
o NCPDP: Bill value of "20" in the Submission Clarification Code field (420-DK).
o NCPDP: Bill value of “08” in the Basis of Cost Determination field (423-DN).
Outpatient/Professional Services 340B Drug Claims:
o CMS 1450/UB04: Enter UD Modifier immediately following drug HCPCS/CPT code in field 44. For
example, HCPCS J1111 billed as J1111UD.
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o CMS 1500: Enter HCPCS code in field 24C followed by the UD Modifier. 837I: Loop 2400 SV2 can
send up to four modifiers SV202-3, SV202-4, SV202-5, and SV202-6.
o 837I: Loop 2400 SV2 can send up to four modifiers SV202-3, SV202-4, SV202-5, and SV202-6
o 837P: Loop 2400 SV1 can send up to four modifiers in SV101-3, SV101-4, SV101-5, and SV101-6.
The MCO shall deny claims at Point of Sale (POS) from 340B carved-in pharmacies that have missing or invalid
claim level indicators. The MCO shall require submission of the UD modifier on 340B outpatient/professional
services drug claims. Encounters shall follow requirements in the Batch Pharmacy Encounters Companion Guide.
Hepatitis C Virus Direct-Acting Antiviral (DAA) Agents
The MCO shall deny claims at POS for hepatitis C direct-acting antiviral agents from 340B pharmacies carved-in to
Medicaid. Claims for hepatitis C direct-acting antiviral agents from 340B carve-out pharmacies are not subject to
this limitation and shall process as usual.
Vaccines for Adults
The MCO shall allow 340B pharmacies carved-in to Medicaid to bill vaccines and administration for adults (19
years and older) at POS as a pharmacy benefit. Claim level indicators should not be required on claims for vaccines.
Vaccines are not 340B or rebate eligible.
Inpatient 340B Drug Claims
Drugs are not billed separately from the per-diem inpatient rate. Per HRSA guidelines, 340B stock must not be
dispensed in an inpatient setting.
340B Exclusion
Only providers registered as 340B covered entities and listed on the HRSA Medicaid Exclusion File may bill drug
stock purchased through 340B with these indicators. The indicator is meant to denote that the specific drug billed
on the claim was obtained through the 340B discount program by the billing provider.
These modifiers should not be used by providers that are not registered 340B covered entities, or by covered
entities that are not listed on the Exclusion File because they have attested that they do not use 340B drug stock
for their Medicaid beneficiaries.
340B contract pharmacies are not permitted to bill 340B stock to Medicaid FFS or MCOs in Louisiana.
The MCO should deny claims at POS if the 340B indicators are on the claim, but the pharmacy is not listed in the
Medicaid Exclusion File. The pharmacy should be directed to fill the claim with regular pharmacy stock with the
denial.
Claims with these modifiers will be excluded from federal Medicaid rebate invoicing only when billed by 340B
covered entities listed on the Medicaid Exclusion file as using their 340B drug stock for Medicaid beneficiaries.
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Emergencies
In the event of an emergency, as defined by LDH, LDH shall have the authority to require the MCOs to implement
any necessary configuration modifications to pharmacy requirements within 72 hours of notification. Within 24
hours from LDH’s request, the MCO shall alter or remove Point of Sale, prior authorization, or other pharmacy
requirements as determined by LDH, in a manner that may be statewide or limited to certain zip codes or parishes.
For an emergency, specific changes shall be determined by LDH and may include:
Point of Sale edits: This may include, but is not limited to, altering early refill and refill too soon edits to
an educational alert (message to pharmacy only, no denial at Point of Sale) as well as altering early refill
and refill too soon edits set to deny so that they return an override code to be utilized by the pharmacy if
needed to bypass the edit, without the requirement of a phone call to the help desk.
Prior authorization requirements: This may include, but is not limited to, altering prior authorization
denials to an educational alert (message to pharmacy only, no denial at Point of Sale) as well as extending
the expiration date of currently approved prior authorizations to a date requested by LDH.
Quantity limitations: This may include, but is not limited to, allowing dispensing of a 90 day supply for
medications specified by LDH.
Copays: This may include, but is not limited to, waiving member copays for pharmacy claims, which shall
be added back to the pharmacy reimbursement.
Signatures: This may include, but is not limited to, removing the requirement of a signature for pick-up or
delivery.
Lock-in restrictions: This may include, but is not limited to, removing pharmacy lock-in restrictions or both
pharmacy and prescriber lock-in restrictions including on a case-by-case basis.
Any other change deemed necessary by LDH to respond to the emergency and protect enrollee health.
PORTABLE X-RAY SERVICES
The MCO shall cover portable x-rays for enrollees who are unable to travel to a physician’s office or outpatient
hospital’s radiology facility.
Covered Services
The MCO shall cover specific diagnostic radiology services for an eligible enrollee to be provided in the enrollee’s
place of residence by an enrolled portable x-ray provider.
Covered radiographs shall be limited to:
Skeletal films of an enrollee’s limbs, pelvis, vertebral column or skull;
Chest films which do not involve the use of contrast media; and
Abdominal films which do not involve the use of contrast media.
NOTE: The MCO shall not reimburse for technical components of these services as a separate part of the service. Providers
billing for these services must bill a full component only.
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The MCO shall cover transportation of portable x-ray equipment only when the equipment used is actually
transported to the location where x-ray services are provided.
The MCO shall reimburse only a single transportation payment per trip to a facility or location for a single date of
service.
The MCO shall require the physician’s order to clearly state the following:
Suspected diagnosis or the reason the x-ray is required;
Area of the body to be exposed;
Number of radiographs ordered; and
Precise views needed.
The enrollee’s place of residence is defined as:
The enrollee’s private home;
A nursing facility; or
An intermediate care facility for the developmentally disabled.
Enrollee Qualifications
Enrollees must be home bound. Enrollees are considered to be homebound when a medical condition causes
them to be unable to leave their place of residence without the use of special transportation or the assistance of
another person. The place of residence may be the enrollee’s own home, a nursing home or an intermediate care
facility for a person with a developmental disability.
Provider Requirements
The MCO shall require providers to comply with the following regarding portable x-rays:
Comply with all Medicare guidelines for portable x-ray providers;
Maintain certification to practice radiology in the state of Louisiana;
Enroll with Louisiana Medicaid as a portable x-ray provider; and
Exist independently of any hospital, clinic, or physician’s office.
The MCO shall ensure that portable x-ray services are provided under the general supervision of a licensed
physician who is qualified by advanced training and experienced in the use of diagnostic x-rays. The supervising
physician is responsible for the ongoing oversight of the quality of the testing performed, the proper operation
and calibration of the equipment used to perform the tests, and the qualifications of non-physician personnel that
use the equipment. Any non-physician personnel utilized by the portable x-ray provider to perform tests must
demonstrate the basic qualifications and possess appropriate training and proficiency as evidence by licensure or
certification.
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PROFESSIONAL SERVICES
Abortion
Induced Abortion
The use of public funds to provide induced abortion services must meet applicable state and federal laws,
including the requirements of the Hyde Amendment (currently found in La. R.S. 40.1061.6 and the Consolidated
Appropriations Act, 2014, Public Law 113-76, Division H, Title V, §506 and §507).
MCO coverage of induced abortion is restricted to those that meet the following criteria:
A physician has found, and so certifies, that on the basis of his/her professional judgment, the life of the
pregnant woman would be endangered if the fetus was carried to term.
The certification statement, which must contain the name and address of the enrollee, must be attached
to the claim form. The diagnosis or medical condition which makes the pregnancy life endangering must
be specified on the claim.
OR
In the case of terminating a pregnancy due to rape or incest the following requirements must be met:
o The enrollee shall report the act of rape or incest to a law enforcement official unless the treating
physician certifies in writing that in the physician’s professional opinion, the victim was too
physically or psychologically incapacitated to report the rape or incest.
o The report of the act of rape or incest to a law enforcement official or the treating physician’s
statement that the victim was too physically or psychologically incapacitated to report the rape
or incest must be submitted to the MCO along with the treating physician’s claim for
reimbursement for performing an abortion.
o The enrollee shall certify that the pregnancy is the result of rape or incest, and this certification
shall be witnessed by the treating physician.
o The “Office of Public Health Certification of Informed Consent-Abortion” form shall be witnessed
by the treating physician.
In order for Medicaid reimbursement to be made for an induced abortion, providers must attach a copy of the
“Office of Public Health Certification of Informed Consent-Abortion” form to their claim form. The form is to be
obtained from the Louisiana Office of Public Health via a request form [link
] or by calling (504) 568-5330.
Claims associated with an induced abortion, including those of the attending physician, hospital, assistant surgeon,
and anesthesiologist must be accompanied by a copy of the attending physician’s certifications, as applicable.
Therefore, the MCO shall require providers to submit only hard-copy claims for payment consideration.
All claim forms and attachments shall be retained by the MCO. The MCO shall forward a copy of the claim and its
accompanying documentation to LDH if requested.
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Threatened, Incomplete or Missed Abortion
As a condition of reimbursement, claims for treatments related to a threatened, incomplete, or missed abortion
must include the enrollee history and complete documentation of treatment.
Supportive documentation that will substantiate reimbursement may include one or more of the following, but is
not limited to:
Sonogram report showing no fetal heart tones;
History indicating passage of fetus at home, en route, or in the emergency room;
Pathology report showing degenerating products of conception; or
Pelvic exam report describing stage of cervical dilation.
Advanced Practice Registered Nurses: Clinical Nurse Specialists,
Certified Nurse Practitioners, and Certified Nurse Midwives
An advanced practice registered nurse (APRN) must hold a current, unencumbered and valid license from the
Louisiana Board of Nursing to participate in Louisiana Medicaid. A nurse licensed as an APRN includes a:
Clinical Nurse Specialist (CNS)
Certified Nurse Practitioner (CNP)
Certified Nurse Midwife (CNM)
Advanced practice registered nurses shall comply with their scope of practice as authorized by Louisiana state law
and regulations.
CNS/CNP/CNMs must obtain an individual Medicaid provider number and, when the rendering provider, must bill
under this provider number for services rendered.
Physicians who employ or contract with CNS/CNP/CNMs must obtain a group provider number and link the
individual CNS/CNP/CNM provider number to the group number.
CNS/CNP/CNMs employed or under contract to a group or facility may not bill individually for the same services
for which reimbursement is made to the group or facility.
Reimbursement
Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual
licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must
be available for review upon request by authorized representatives of the Medicaid program and contracted
MCOs.
Immunizations, physician-administered drugs, long-acting reversible contraceptives, and Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) medical, vision, and hearing screens are reimbursed at a minimum
of 100% of the physician fee on file. All other payable procedures are reimbursed at a minimum of 80% of the
physician fee on file.
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After Hours Care on Evenings, Weekends, and Holidays
This policy is intended to facilitate enrollee access to services during non-typical hours primarily to reduce the
inappropriate use of the hospital emergency department. The reimbursement for the evening, weekend, and
holiday codes is intended to assist with coverage of the additional administrative costs associated with staffing
during these times.
The Current Procedural Terminology (CPT) evening, weekend, and holiday codes are reimbursed in addition to the
reimbursement for most outpatient evaluation and management (E&M) services when the services are rendered
in settings other than hospital emergency departments during the hours of:
Monday through Friday between 5 p.m. and 8 a.m. (when outside of regular office hours),
Weekends (12 a.m. Saturday through midnight on Sunday), or
State/Governor proclaimed legal holidays (12 a.m. through midnight).
Only one of the evening, weekend, and holiday codes may be submitted by a billing provider per day per enrollee.
Providers should select the evening, weekend, and holiday procedure code that most accurately reflects the
situation on a particular date. These codes are never reported alone, but rather in addition to another code or
codes describing the service related to that enrollee’s visit or encounter. The following examples illustrate the
appropriate use of evening, weekend, and holiday procedure codes based on the situation described.
If the existing office hours are Monday through Friday from 8 a.m. to 5 p.m., and the physician treats the
enrollee in the office at 7 p.m., then the provider may report the appropriate basic service (E&M visit
code) and evening, weekend, and holiday code.
If the existing office hours are Monday through Friday from 8:30 a.m. to 6:30 p.m., and the physician
treats the enrollee in the office at 6 p.m., then the provider may not report the evening, weekend, and
holiday code.
If an enrollee is seen in the office on Saturday during existing office hours, then the provider may report
the appropriate basic service (E&M visit code) and evening, weekend, and holiday code.
Documentation in the medical record relative to this reimbursement must include the time the services were
rendered.
Reimbursement
The reimbursement for evening, weekend and holiday services is based on the following current CPT codes or
their successors.
99050 (Services…at times other than regularly scheduled office hours…) or
99051 (Services …at regularly scheduled evening, weekend, or holiday hours…).
When used, these procedure codes must be submitted with the code(s) for the associated evaluation and
management services on that date.
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Allergy Testing and Allergen Immunotherapy
The MCO shall cover allergy testing and allergen immunotherapy relating to hypersensitivity disorders manifested
by generalized systemic reactions as well as by localized reactions in any organ system of the body. Covered allergy
services shall include:
In vitro specific IgE tests;
Intracutaneous (intradermal) skin tests;
Percutaneous skin tests;
Ingestion challenge testing; and
Allergen immunotherapy.
Allergy Testing
The MCO shall cover allergy testing for enrollees who have symptoms of allergic disease, such as respiratory
symptoms, skin symptoms, or other symptoms that consistently follow a particular exposure, not including local
reactions after an insect sting or bite.
Allergen Immunotherapy
The MCO shall cover allergen immunotherapy at:
Up to 180 doses every calendar year, per enrollee, for supervision of preparation and provision of antigens
other than stinging or biting insects; and
Up to 52 doses every calendar year, per enrollee, for supervision of preparation and provision of antigens
related to stinging or biting insects;
The MCO shall cover allergen immunotherapy doses exceeding the above quantities when medically necessary.
Anesthesia
Surgical Anesthesia
The MCO shall cover surgical anesthesia services when provided by an anesthesiologist or certified registered
nurse anesthetist (CRNA).
Coverage for surgical anesthesia procedures must be based on formulas utilizing base units, time units (1 unit =
15 min) and a conversion factor as identified in the Anesthesia Fee Schedules. Minutes must be reported on
anesthesia claims.
Administration of anesthesia by the provider performing the surgical procedure for a non-obstetrical surgery shall
not be covered.
The MCO shall require the following modifiers to be used to submit surgical anesthesia services:
Modifier
Servicing Provider
Surgical Anesthesia Service
AA
Anesthesiologist
Anesthesia services performed personally by the anesthesiologist
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*See Medical Direction for further explanation.
The following are acceptable uses of modifiers:
Modifiers which can stand alone: AA and QZ;
Modifiers which need a partner: QK, QX and QY; and
Valid combinations: QK and QX, or QY and QX.
Medical Direction
Medical direction is defined as:
Performing a pre-anesthetic examination and evaluation;
Prescribing the anesthesia plan;
Participating personally in the most demanding procedures in the anesthesia plan, including induction and
emergence;
Ensuring that any procedures in the anesthesia plan that he/she does not perform are rendered by a
qualified individual;
Monitoring the course of anesthesia administration at frequent intervals;
Remaining physically present and available for immediate diagnosis and treatment of emergencies; and
Providing the indicated post-anesthesia care.
The MCO shall reimburse only anesthesiologists for medical direction.
Maternity-Related Anesthesia
The MCO shall cover maternity-related anesthesia services when provided by anesthesiologists, CRNAs, or the
delivering physician.
The MCO shall require the delivering physician to use CPT codes in the Surgery Maternity Care and Delivery section
of the CPT manual to bill for maternity-related anesthesia services.
Reimbursement for these services shall be a flat fee, except for general anesthesia for vaginal delivery.
The MCO shall require the following modifiers to be used when providing maternity-related anesthesia services:
Modifier
Servicing Provider
Service Performed
AA
Anesthesiologist
Anesthesia services performed personally by the anesthesiologist
QY
Anesthesiologist
Medical direction* of one CRNA
QK
Anesthesiologist
Medical direction* of two, three, or four concurrent anesthesia procedures
QX
CRNA
CRNA service with medical direction* by an anesthesiologist
QZ
CRNA
CRNA service without medical direction* by an anesthesiologist
47
Delivering Physician
Anesthesia provided by delivering physician
QY
Anesthesiologist
Medical direction* of one CRNA
QK
Anesthesiologist
Medical direction* of two, three, or four concurrent anesthesia
procedures involving qualified individuals
QX
CRNA
CRNA service with direction* by an anesthesiologist
QZ
CRNA
CRNA service without medical direction* by an anesthesiologist
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52
Delivering Physician or
Anesthesiologist
Reduced services
QS
Anesthesiologist or CRNA
Monitored anesthesia care service
The QS modifier is a secondary modifier only, and must be paired with the
appropriate anesthesia provider modifier (either the anesthesiologist or the
CRNA).
The QS modifier indicates that the provider did not introduce the epidural for
anesthesia, but did monitor the enrollee after catheter placement.
*See Medical Direction section for further explanation.
Add-on Codes for Maternity-Related Anesthesia
When an add-on code is used to fully define a maternity-related anesthesia service, the MCO shall require the
date of delivery be the date of service for both the primary and add-on code.
An add-on code in and of itself is not a full service and typically cannot be reimbursed separately to different
providers. The exception is when more than one provider performs services over the duration of labor and
delivery.
A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-
anesthesia examination/evaluation, and another may fulfill other criteria. The MCO shall require that the medical
record indicate the services provided and identify the provider who rendered the service.
Maternity-Related Anesthesia
Reimbursement for maternity-related procedures, other than general anesthesia for vaginal delivery, shall be a
flat fee.
The MCO shall ensure that minutes be reported on all maternity-related anesthesia claims.
The MCO shall require providers to follow the chart below when billing for maternity-related anesthesia.
Type of Anesthesia
CPT Code
Modifier
Reimbursement
Service
Vaginal Delivery
General Anesthesia
01960
Valid Modifier
Formula
Anesthesiologist performs
complete service, or direction of
the CRNA
CRNA performs complete service
with or without direction by
Anesthesiologist
Epidural for Vaginal
Delivery
01967
AA, QY or QK for MD;
QX or QZ for CRNA
Flat Fee
See modifier list for maternity-
related services
Cesarean Delivery
only (epidural or
general)
01961
AA, QY or QK for MD;
QX or QZ for CRNA
Flat Fee
See modifier list for maternity-
related services
Cesarean Delivery
after Epidural, for
planned vaginal
delivery
01967
+ 01968
AA, QY or QK for MD;
QX or QZ for CRNA
Flat Fee plus add-on
See modifier list for maternity-
related services
Cesarean
Hysterectomy after
01967
+ 01969
AA, QY or QK for MD;
QX or QZ for CRNA
Flat Fee plus add-on
See modifier list for maternity-
related services
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Epidural and
Cesarean Delivery
Epidural – Vaginal
Delivery
59409
59612
47
Fee for delivery plus
additional
reimbursement for
anesthesia
Delivering physician provides the
entire service for vaginal delivery
Epidural – Vaginal
Delivery
59409
59612
47 and 52
Fee for delivery plus
additional
reimbursement for
anesthesia
Introduction only by the delivering
physician
Epidural – Vaginal
Delivery
01967
AA and 52
Flat Fee
Introduction only by
anesthesiologist
Epidural – Vaginal
Delivery
01967
AA and QS for MD;
QZ and QS or QX and
QS for CRNA
Flat Fee
Monitoring by anesthesiologist or
CRNA
Cesarean Delivery
59514
59620
47 and 52
Fee for delivery plus
additional
reimbursement for
anesthesia
Introduction only by the delivering
physician
Cesarean Delivery –
after Epidural
01961
AA and 52
Flat Fee
Introduction only by the
anesthesiologist
Cesarean Delivery-
following Epidural for
planned vaginal
delivery
01967
+ 01968
AA and 52
Flat Fee plus add-on
Introduction only by the
anesthesiologist
Cesarean Delivery –
after Epidural
01961
AA and QS for MD;
QZ and QS or QX and
QS for CRNA
Flat Fee
Monitoring by the anesthesiologist
or CRNA
Cesarean Delivery-
following Epidural for
planned vaginal
delivery
01967
+ 01968
AA and QS for MD;
QZ and QS or QX and
QS for CRNA
Flat Fee plus add-on
Monitoring by the anesthesiologist
or CRNA
Anesthesia for Tubal Ligation or Hysterectomy
Anesthesia reimbursement for tubal ligations and hysterectomies shall be formula-based, with the exception of
anesthesia for cesarean hysterectomy (CPT code 01969).
The reimbursement for CPT codes 01967 and 01969, when billed together, shall be a flat fee. CPT code 01968 is
implied in CPT code 01969 and should not be placed on the claim form if a cesarean hysterectomy was performed
after cesarean section delivery.
Pediatric Moderate (Conscious) Sedation
Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care.
Moderate sedation coverage shall be restricted to enrollees from birth to age 13. Exceptions to the age restriction
shall be made for children who have severe developmental disabilities; however, no claims shall be considered
for enrollees 21 years of age or older.
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Moderate sedation includes the following services (which are not to be reported/billed separately):
Assessment of the enrollee (not included in intra-service time);
Establishment of intravenous (IV) access and fluids to maintain patency, when performed;
Administration of agents;
Maintenance of sedation;
Monitoring of oxygen saturation, heart rate and blood pressure; and
Recovery (not included in intra-service time).
Intra-service time starts with the administration of the sedation agents, requires continuous face-to-face
attendance, and ends at the conclusion of personal contact by the physician providing the sedation.
The MCO shall reimburse a second physician other than the healthcare professional performing the diagnostic or
therapeutic when the second physician provides moderate sedation in a facility setting (e.g., hospital, outpatient
hospital, ambulatory surgical center, skilled nursing facility). However, moderate sedation services performed by
a second physician in a non-facility setting (e.g., physician office, freestanding imaging center) should not be
reported.
Pain Management
The MCO shall cover epidurals that are administered for the prevention or control of acute pain, such as that
which occurs during delivery or surgery, as professional services for this purpose only.
Chronic Intractable Pain
Coverage for chronic intractable pain is dependent on the clinical etiology and the type of service or treatment.
The MCO’s coverage policy shall include the provisions within this section.
If an enrollee requests treatment for chronic intractable pain, depending on the underlying cause or anatomical
defect, the provider may determine treatment or management to include physical therapy, occupational therapy,
medication therapy management (MTM), epidural steroid injection (ESI) therapy, acupuncture, chiropractic,
behavioral health and addiction medicine services in coordination with case management. These include some
alternative treatments, and the inclusion of coverage on the Professional Services Fee Schedule will define
covered treatments. The MCO may offer additional treatments via authorized in lieu of services or value-added
benefits.
Certain Medicaid procedures or services may require prior authorization. CPT codes for the treatment of chronic
intractable pain requiring PA can be identified on the Professional Services Fee Schedule.
Note: Medical necessity for epidural steroid injection (ESI) shall be determined by the history of illness, physical examination,
and concordant diagnostic imaging supporting radiculopathy, radicular pain, or neurogenic claudication due to herniation,
stenosis, and/or degenerative disease protracted and severe enough to greatly impact quality of life or function.
Provider Claims Filing
The MCO’s policy for filing of claims related to anesthesia services shall include the following.
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Anesthesia Time
Anesthesia time begins when the provider begins to prepare the enrollee for induction and ends with termination
of the administration of anesthesia. Time spent in pre- and postoperative care may not be included in the total
anesthesia time.
Multiple Surgical Procedures
Anesthesia for multiple surgical (non-OB) procedures in the same anesthesia session must be billed on one claim
line using the most appropriate anesthesia code with the total anesthesia time spent reported in item 24G on the
claim form. The only secondary procedures that are not to be billed in this manner are tubal ligations and
hysterectomies.
Vaginal Delivery – Complete Anesthesia Service by Delivering Physician
The delivering physician should submit a claim for the delivery and anesthesia on a single claim line with modifier.
Assistant Surgeon/Assistant at Surgery
The MCO shall reimburse for only one assistant at surgery. The assistant to the surgeon should be a qualified
physician. However, in those situations when a physician does not serve as the assistant, qualified, enrolled,
advanced practice registered nurses and physician assistants may function in the role of an assistant at surgery
and submit claims for their services under their Medicaid provider number.
Physicians serving as the assistant are to use the modifier “80” on the procedure code(s) representing their
services.
Advanced practice registered nurses, certified nurse midwives, and physician assistants are to use the modifier
“AS” when reporting their services as the only assistant at surgery.
Bariatric Surgery
Bariatric surgery consists of open or laparoscopic procedures that revise the gastrointestinal anatomy to restrict
the size of the stomach, reduce absorption of nutrients, or both.
Eligibility Criteria
The MCO shall cover bariatric surgery when medically necessary, as determined by meeting all of the following
criteria:
The enrollee has received a preoperative evaluation within the previous 12 months that is conducted by
a multidisciplinary team including, at a minimum, a physician, nutritionist or dietician, and a licensed
qualified mental health professional. For enrollees under the age of 18, the multidisciplinary team must
have pediatric expertise. For all enrollees, the preoperative evaluation must document all of the following:
o A determination that previous attempt(s) at weight loss have been unsuccessful and that future
attempts, other than bariatric surgery, are not likely to be successful; and
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o A determination that the enrollee is capable of adhering to the post-surgery diet and follow-up
care; and
o For individuals capable of becoming pregnant, counseling to avoid pregnancy preoperatively and
for at least 12 months postoperatively and until weight has stabilized.
Enrollees age 18 and older must have:
o A body mass index equal to or greater than 40 kg/m
2
, or more than 100 pounds overweight; or
o A body mass index of greater or equal to 35 kg/m
2
with one or more comorbidities related to
obesity:
Type 2 diabetes mellitus,
Cardiovascular disease (e.g., stroke, myocardial infarction, poorly controlled hypertension
(systemic blood pressure greater than 140 mm Hg or diastolic blood pressure 90 mm Hg
or greater, despite pharmacotherapy),
History of coronary artery disease with a surgical intervention such as coronary artery
Bypass or percutaneous transluminal coronary angioplasty,
History of cardiomyopathy,
Obstructive sleep apnea confirmed on polysomnography with an AHI or RDI of ≥ 30, or
Any other comorbidity related to obesity that is determined by the preoperative
evaluation to be improved by weight loss; or
o A body mass index of 30 to 34.9 kg/m
2
with type 2 diabetes mellitus if hyperglycemia is
inadequately controlled despite optimal medical control by oral or injectable medications.
Enrollees age 13 through 17 years old must have:
o A body mass index equal to or greater than 40 kg/m
2
or 140% of the 95
th
percentile for age and
sex, whichever is lower; or
o A body mass index of 35 to 39.9 kg/m
2
or 120% of the 95
th
percentile for age and sex, whichever
is lower, with one or more comorbidities related to obesity:
Obstructive sleep apnea confirmed on polysomnography with an AHI > 5,
Type 2 diabetes mellitus,
Idiopathic intracranial hypertension
Nonalcoholic steatohepatitis,
Blount’s disease,
Slipped capital femoral epiphysis,
Gastroesophageal reflux disease,
Hypertension, or
Any other comorbidity related to obesity that is determined by the preoperative
evaluation to be improved by weight loss.
The MCO shall review the medical necessity of requests for bariatric surgery for enrollees under the age
of 13 on a case-by-case basis.
Panniculectomy Subsequent to Bariatric Surgery
The MCO shall cover panniculectomy after bariatric surgery when medically necessary, as determined by the
following criteria:
The enrollee had bariatric surgery at least 18 months prior and the enrollee’s weight has been stable for
at least 6 months; and
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The pannus is at or below the level of the pubic symphysis; and
The pannus causes significant consequences, as indicated by at least one of the following:
o Cellulitis, other infections, skin ulcerations, or persistent dermatitis that has failed to respond to
at least 3 months of non-surgical treatment; or
o Functional impairment such as interference with ambulation.
Breast Surgery
Mastectomy
The MCO shall cover mastectomy and breast conserving surgery when medically necessary.
Risk-reducing mastectomy to prevent cancer shall be considered medically necessary for enrollees that meet all
of the following criteria:
A high risk of breast cancer, as defined by one or more of the following:
o Positive genetic mutation that is known or likely to confer a high risk of breast cancer (e.g., BRCA1
and BRCA2) where risk-reducing mastectomy is recommended by National Comprehensive
Cancer Network guidelines; or
o Significant family history, as defined by meeting the family history criteria listed under “Breast
and Ovarian Cancer” within the “Genetic Testing” policy; or
o Prior thoracic radiation therapy at an age less than 30 years old; and
A life expectancy greater than or equal to 10 years.
Breast Reconstruction
The MCO shall cover reconstructive breast surgery after a therapeutic intervention (e.g., mastectomy) or trauma
resulting in significant loss of breast tissue.
The following services shall be considered medically necessary:
Reconstruction of the affected breast;
Reconstruction of the contralateral breast to produce a symmetrical appearance;
Prostheses (implanted, external, or both); and
Treatment of complications of the reconstruction.
All prosthetic implants must be FDA approved and used in compliance with all FDA requirements at the time of
the surgery.
Reduction Mammaplasty and Removal of Breast Implants
The MCO shall cover reduction mammaplasty and removal of breast implants for the purpose of breast
reconstruction under the above breast reconstruction policy.
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Reduction mammaplasty for purposes other than reconstruction shall be considered medically necessary when
all of the following criteria are met:
Pubertal breast development is complete;
A diagnosis of macromastia with at least two of the following symptoms for at least a 12-week duration:
o Chronic breast pain
o Headache
o Neck, shoulder, or back pain
o Shoulder grooving from bra straps
o Upper extremity paresthesia due to brachial plexus compression syndrome, secondary to the
weight of the breasts being transferred to the shoulder strap area
o Thoracic kyphosis
o Persistent skin condition such as intertrigo in the inframammary fold that is unresponsive to
medical management
o Congenital breast deformity;
There is a reasonable likelihood that the symptoms are primarily due to macromastia; and
The amount of breast tissue to be removed is reasonably expected to alleviate the symptoms.
Removal of breast implants for purposes other than reconstruction shall be considered medically necessary for
the following indications:
Visible capsular contracture causing pain (Baker Grade IV)
Diagnosed or suspected implant rupture
Local or systemic infection
Siliconoma or granuloma
Implant extrusion
Interference with the diagnosis or treatment of breast cancer
Breast implant-associated anaplastic large cell lymphoma
If an indication for medically necessary removal of breast implants is present unilaterally, removal of the
contralateral breast implant shall also be considered medically necessary when performed during the same
operative session.
When the procedure is not reconstructive and is performed solely for the purpose of altering the appearance of
the breast, reduction mammaplasty and removal of breast implants shall be considered cosmetic and not
medically necessary.
Cardiovascular Services
Invasive Coronary Angiography and Percutaneous Coronary
Intervention
The MCO shall cover elective invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI)
as treatment for cardiovascular conditions under specific circumstances. ICA for non-acute, stable coronary artery
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disease is not considered medically necessary, including for patients with stable angina who are not interested in
revascularization or who are not candidates for PCI or coronary artery bypass graft surgery.
This policy only applies to enrollees age 18 and older and does not apply to the following enrollees:
Enrollees under the age of 18;
Pregnant enrollees;
Cardiac transplant enrollees;
Solid organ transplant candidates; and
Survivors of sudden cardiac arrest.
Eligibility Criteria
Elective Invasive Coronary Angiography (ICA)
The MCO shall cover elective ICA and consider it medically necessary in enrollees with one or more of the
following:
Congenital heart disease that cannot be characterized by non-invasive modalities such as cardiac
ultrasound, CT, or MRI;
Heart failure with reduced ejection fraction for the purposes of diagnosing ischemic cardiomyopathy;
Hypertrophic cardiomyopathy prior to septal ablation or myomectomy;
Severe valvular disease or valvular disease with plans for surgery or percutaneous valve replacement;
Type 1 myocardial infarction within the past three months defined by detection of a rise and/or fall of
cardiac troponin values with at least one value above the 99th percentile upper reference limit and with
at least one of the following:
o Symptoms of acute myocardial ischemia;
o New ischemic electrocardiogram (ECG) changes;
o Development of pathological Q waves;
o Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a
pattern consistent with an ischemic etiology; and
o Identification of a coronary thrombus;
History of ventricular tachycardia requiring therapy for termination or sustained ventricular tachycardia
not due to a transient reversible cause, within the past year;
History of ventricular fibrillation;
Return of angina within nine months of prior PCI;
Enrollees without chronic kidney disease who have Canadian Cardiovascular Society class I-IV classification
of angina with intolerance of or failure to respond to at least two target dose anti-anginal medications
(beta blocker, dihydropyridine or non-dihydropyridine calcium channel blocker, nitrates, and/or
ranolazine); or
High risk imaging findings, defined as one or more of the below:
o Severe resting left ventricular dysfunction (LVEF ≤35%) not readily explained by noncoronary
causes;
o Resting perfusion abnormalities ≥10% of the myocardium in enrollees without prior history or
evidence of myocardial infarction;
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o Stress electrocardiogram findings including ≥2 mm of ST-segment depression at low workload or
persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced ventricular
tachycardia/ventricular fibrillation;
o Severe stress-induced left ventricular dysfunction (peak exercise LVEF <45% or drop in LVEF with
stress ≥10%);
o Stress-induced perfusion abnormalities affecting ≥10% myocardium or stress segmental scores
indicating multiple vascular territories with abnormalities;
o Stress-induced left ventricular dilation;
o Inducible wall motion abnormality (involving >2 segments or 2 coronary beds);
o Wall motion abnormality developing at low dose of dobutamine (≥10 mg/kg/min) or at a low heart
rate (<120 beats/min); or
o Left main stenosis (≥50% stenosis) on coronary computed tomography angiography.
Elective Percutaneous Coronary Intervention (PCI)
The MCO shall cover elective PCI for angina with stable coronary artery disease and consider it medically necessary
in:
Enrollees without chronic kidney disease who have Canadian Cardiovascular Society class I-IV classification
of angina with intolerance of or failure to respond to at least two target dose anti-anginal medications
(beta blocker, dihydropyridine or non-dihydropyridine calcium channel blocker, nitrates, and/or
ranolazine).
Elective PCI for other cardiac conditions is considered medically necessary in enrollees with one or more of the
following:
Heart failure with reduced ejection fraction for the purposes of treating ischemic cardiomyopathy;
Left main stenosis ≥50% as determined on prior cardiac catheterization or coronary computed
tomography angiography, if the enrollee has documentation indicating they were declined for a coronary
artery bypass graft surgery; and
Type 1 myocardial infarction within the past three months as defined by detection of a rise and/or fall of
cardiac troponin values with at least one value above the 99th percentile upper reference limit and with
at least one of the following:
o Symptoms of acute myocardial ischemia;
o New ischemic electrocardiogram changes;
o Development of pathological Q waves;
o Imaging evidence of new loss of viable myocardium, or new regional wall motion abnormality in
a pattern consistent with an ischemic etiology; and
o Identification of a coronary thrombus.
Elective PCI for non-acute, stable coronary artery disease is not considered medically necessary in all other
enrollee populations, including if the enrollee is unwilling to adhere with recommended medical therapy, or if the
enrollee is unlikely to benefit from the proposed procedure (e.g., life expectancy less than six months due to a
terminal illness).
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Endovascular Revascularization for Peripheral Artery Disease
The MCO shall cover endovascular revascularization procedures (stents, angioplasty, and atherectomy) for the
lower extremity and consider them medically necessary for the following conditions:
Acute limb ischemia;
Chronic limb-threatening ischemia, defined as the presence of any of the following:
o Ischemic pain at rest;
o Gangrene; or
o Lower limb ulceration greater than two weeks duration.
The MCO shall also cover endovascular revascularization procedures and consider them medically necessary in
enrollees with peripheral artery disease who have symptoms of intermittent claudication and meet all of the
following criteria:
Significant peripheral artery disease of the lower extremity as indicated by at least one of the following:
o Moderate to severe ischemic peripheral artery disease with ankle-brachial index (ABI) ≤0.69; or
o Stenosis in the aortoiliac artery, femoropopliteal artery, or both arteries, with a severity of
stenosis ≥70% by imaging studies; and
Claudication symptoms that impair the ability to work or perform activities of daily living; and
No improvement of symptoms despite all of the following treatments:
o Documented participation in a medically supervised or directed exercise program for at least 12
weeks. Individuals fully unable to perform exercise therapy may qualify for revascularization only
if the procedure is expected to provide long-term functional benefits despite the limitations that
precluded exercise therapy; and
o At least six months of optimal pharmacologic therapy including all of the below agents, unless
contraindicated or discontinued due to adverse effects:
Antiplatelet therapy with aspirin, clopidogrel, or both
Statin therapy
Cilostazol
Antihypertensives to a goal systolic blood pressure ≤140 mmHg and diastolic blood
pressure ≤90 mmHg; and
o At least one documented attempt at smoking cessation, if applicable, consisting of
pharmacotherapy, unless contraindicated, and behavioral counseling, or referral to a smoking
cessation program that offers both pharmacotherapy and counseling.
Exclusions
The MCO shall not consider endovascular revascularization procedures for the lower extremity not medically
necessary in the following circumstances:
Claudication due to isolated infrapopliteal artery disease (anterior tibial, posterior tibial or peroneal)
including enrollees with coronary artery disease, diabetes mellitus, or both;
To prevent the progression of claudication to chronic limb-threatening ischemia in an enrollee who does
not otherwise meet medical necessity criteria;
Enrollee is asymptomatic; or
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Treatment of a nonviable limb.
Peripheral Arterial Disease Rehabilitation for Symptomatic
Peripheral Arterial Disease
Peripheral arterial disease rehabilitation, also known as supervised exercise therapy, involves the use of
intermittent exercise training for the purpose of reducing intermittent claudication symptoms.
The MCO shall cover and consider medically necessary up to 36 sessions of peripheral arterial disease
rehabilitation annually. Delivery of these sessions three times per week over a 12-week period is recommended,
but not required. The MCO shall direct providers to adhere to CPT guidance on the time per session, exercise
activities permitted, and the qualifications of the supervising provider.
Chiropractic Services
The MCO shall cover chiropractic manipulative treatment for enrollees under 21 years of age when medically
necessary and upon referral from an EPSDT medical screening primary care provider.
Cochlear Implant
The MCO shall cover unilateral or bilateral cochlear implants when deemed medically necessary for the treatment
of severe-to-profound, bilateral sensorineural hearing loss in enrollees under 21 years of age. The MCO shall direct
providers that any implant must be used in accordance with Food and Drug Administration (FDA) guidelines.
Eligibility Criteria
The MCO shall require a multidisciplinary implant team to collaborate on determining eligibility and providing care
that includes, at minimum: a fellowship-trained pediatric otolaryngologist or fellowship-trained otologist, an
audiologist, and a speech-language pathologist.
An audiological evaluation must find:
Severe-to-profound hearing loss determined through the use of an age-appropriate combination of
behavioral and physiological measures; and
Limited or no functional benefit achieved after a sufficient trial of hearing aid amplification.
A medical evaluation must include:
Medical history;
Physical examination verifying the candidate has intact tympanic membrane(s), is free of active ear
disease, and has no contraindication for surgery under general anesthesia;
Verification of receipt of all recommended immunizations;
Verification of accessible cochlear anatomy that is suitable to implantation, as confirmed by imaging
studies (computed tomography (CT) and/or magnetic resonance imagery (MRI)), when necessary; and
Verification of auditory nerve integrity, as confirmed by electrical promontory stimulation, when
necessary.
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For bilateral cochlear implants, an audiologic and medical evaluation must determine that a unilateral cochlear
implant plus hearing aid in the contralateral ear will not result in binaural benefit for the enrollee.
Non-audiological evaluations must include:
Speech and language evaluation to determine enrollee’s level of communicative ability; and
Psychological and/or social work evaluation, as needed.
Pre-operative counseling must be provided to the enrollee, if age appropriate, and the enrollee’s caregiver and
must provide:
Information on implant components and function; risks, limitations, and potential benefits of
implantation; the surgical procedure; and postoperative follow-up schedule;
Appropriate post-implant expectations, including being prepared and willing to participate in pre- and
post- implant assessment and rehabilitation programs; and
Information about alternative communication methods to cochlear implants.
Preoperative Evaluation
If prior authorized, the MCO shall reimburse for preoperative evaluation services (i.e., evaluation of speech,
language, voice, communication, auditory processing, and/or audiologic/aural rehabilitation) even when the
enrollee may not subsequently receive an implant.
Implants, Equipment, Repairs, and Replacements
At the time of surgery, the MCO shall make reimbursement to the hospital for both the implant and the per diem.
Refer to the Inpatient Hospital Services section of this Manual for specific information.
The MCO shall cover other necessary equipment, repairs, and replacements according to the Durable Medical
Equipment Provider Manual chapter of the Medicaid Services Manual.
Implantation Procedure, Postoperative Rehabilitative Costs, and
Subsequent Therapy
The MCO shall cover the cochlear implant surgery as well as postoperative aural rehabilitation by an audiologist
and subsequent speech, language, and hearing therapy.
Post-Operative Programming
The MCO shall cover cochlear implant post-operative programming and diagnostic analysis services.
Community Health Workers
The MCO shall cover services rendered to enrollees by qualified community health workers (CHW) meeting the
criteria and policy outlined below.
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Community Health Worker Qualifications
A qualified Community Health Worker is defined as someone who:
Has completed state-recognized training curricula approved by the Louisiana Community Health Worker
Workforce Coalition; or
Has a minimum of 3,000 hours of documented work experience as a CHW.
The MCO shall require providers who employ CHWs to verify and maintain and provide documentation, as
requested by LDH, that qualification criteria are met.
Eligibility Criteria
The MCO shall cover CHW services if an enrollee has one or more of the following:
Diagnosis of one or more chronic health (including behavioral health) conditions;
Suspected or documented unmet health-related social need; or
Pregnancy.
Covered Services
Covered services include:
Health promotion and coaching. This can include assessment and screening for health-related social
needs, setting goals and creating an action plan, on-site observation of enrollees’ living situations, and
providing information and/or coaching in an individual or group setting.
Care planning with the enrollee and their healthcare team. This should occur as part of a person-centered
approach to improve health by meeting an enrollee’s situational health needs and health-related social
needs, including time-limited episodes of instability and ongoing secondary and tertiary prevention.
Health system navigation and resource coordination services. This can include helping to engage, re-
engage, or ensure patient follow-up in primary care; routine preventive care; adherence to treatment
plans; and/or self-management of chronic conditions.
Services must be ordered by a physician, advanced practice registered nurse (APRN), or physician assistant (PA)
with an established clinical relationship with the enrollee. Services must be rendered under this supervising
provider’s general supervision, defined as under the supervising provider’s overall direction and control, but the
provider’s presence is not required during the performance of the CHW services.
The MCO shall not restrict the site of service which may include, but is not limited to, a health care facility, clinic
setting, community setting, or the enrollee’s home. The MCO shall permit delivery of the service through a
synchronous audio/video telehealth modality.
The MCO shall reimburse only the CPT procedure codes in the ‘Education and Training for Patient Self-
Management’ section that are provided by CHWs. The MCO shall direct CHWs to follow CPT guidance.
Coverage Limitations
The MCO shall not cover the following services when provided by CHWs:
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Insurance enrollment and insurance navigator assistance;
Case management;
Direct provision of transportation for an enrollee to and from services; and
Direct patient care outside the level of training an individual has attained.
The MCO shall reimburse a maximum of two hours per day and ten hours per month per enrollee.
Reimbursement
The MCO shall reimburse CHW services “incident to” the supervising physician, APRN, or PA.
The MCO shall require a CHW who provides services to more than one enrollee to document in the clinical record
and bill appropriately using the approved codes associated with the number of people receiving the service
simultaneously. This shall be limited to eight unique enrollees per session.
Concurrent Care – Inpatient
The MCO shall cover inpatient concurrent care when an enrollee’s condition requires the care of more than one
provider on the same day and the services rendered by each individual provider are medically necessary and not
duplicative.
The MCO shall separately reimburse providers from different specialties/subspecialties, whether from the same
group or a different group. Each provider from a different specialty/subspecialty can be reimbursed for one initial
hospital visit per admission plus a maximum of one subsequent hospital visit per day.
Within the same specialty/subspecialty, only one provider can be reimbursed for one initial hospital visit per
admission and, subsequently, only one provider can be reimbursed for a maximum of one subsequent hospital
visit per day.
The MCO shall reimburse only the provider responsible for discharging the enrollee for hospital discharge services
on the discharge day.
Diabetes Self-Management Training
The MCO shall cover diabetes self-management training (DSMT) services which, at a minimum, must include the
following:
Instructions for blood glucose self-monitoring;
Education regarding diet and exercise;
Individualized insulin treatment plan (for insulin dependent enrollees); and
Encouragement and support for use of self-management skills.
DSMT must be aimed at educating enrollees on the following topics to promote successful self-management:
Diabetes overview, including current treatment options and disease process;
Diet and nutritional needs;
Increasing activity and exercise;
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Medication management, including instructions for self-administering injectable medications (as
applicable);
Management of hyperglycemia and hypoglycemia;
Blood glucose monitoring and utilization of results;
Prevention, detection, and treatment of acute and chronic complications associated with diabetes
(including discussions on foot care, skin care, etc.);
Reducing risk factors, incorporating new healthy behaviors into daily life, and setting goals to promote
successful outcomes;
Importance of preconception care and management during pregnancy;
Managing stress regarding adjustments being made in daily life; and
Importance of family and social support.
All educational material must be pertinent and age appropriate for each enrollee. Parents or legal guardians can
participate in DSMT rendered to their child, but all claims for these services must be submitted under the child’s
Medicaid coverage.
Provider Qualifications
DSMT is not a separately recognized provider type and the MCO shall require that DSMT services be provided and
reimbursed under the direction of a physician, advanced practice registered nurse, or physician assistant.
Accreditation
The MCO shall require providers of DSMT services to be accredited by one of the following national accreditation
organizations:
American Diabetes Association (ADA),
American Association of Diabetes Educators (AADE), or
Indian Health Service (IHS).
The MCO shall not cover services provided by providers without proof of accreditation from one of the listed
organizations.
At a minimum, providers of DSMT services must include at least one registered dietician, registered nurse, or
pharmacist. Each enrollee of the instructional team must be a Certified Diabetes Educator (CDE) or have recent
didactic and experiential preparation in education and diabetes management, and at least one member of the
instructional team must be a CDE who has been certified by the National Certification Board for Diabetes
Educators (NCBDE). The MCO shall require providers to maintain and provide proof of certification of staff
members as requested by LDH or its fiscal intermediary.
All DSMT services must adhere to the National Standards for Diabetes Self-Management Education.
Coverage Requirements
The MCO shall cover DSMT for eligible enrollees who have been diagnosed with type 1, type 2, or gestational
diabetes mellitus and who have an order from a provider involved in the management of their diabetes, such a
primary care provider or obstetrician.
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The MCO shall require the ordering provider to maintain a copy of all DSMT orders. Each order must be signed
and must specify the total number of hours being ordered, not to exceed the following coverage limitations:
A maximum of 10 hours of initial training (one hour of individual and nine hours of group sessions) are
allowed during the first 12-month period beginning with the initial training date.
A maximum of two hours of individual sessions are allowed for each subsequent year.
If special circumstances occur in which the ordering provider determines an enrollee would benefit from individual
sessions rather than group sessions, the order must also include a statement specifying that individual sessions
would be more appropriate, along with an explanation.
If a DSMT order must be modified, the updated order must be signed by the ordering provider and copies must
be retained in the medical record.
Medicaid Enrollees Not Eligible for DSMT
The following enrollees are not eligible for DSMT:
Enrollees residing in an inpatient hospital or other institutional setting such as an nursing care facility or
a residential care facility; and
Enrollees receiving hospice services.
Initial DSMT
The MCO’s policy for initial DSMT shall include the following:
Initial DSMT may begin after receiving the initial order. DSMT is allowed for a continuous 12- month period
following the initial training date. In order for services to be considered initial, the enrollee must not have
previously received initial or follow up DSMT.
The 10 hours of initial training may be provided in any combination of 30-minute increments over the 12-
month period. The MCO should not reimburse for sessions lasting less than 30 minutes.
Group sessions may be provided in any combination of 30-minute increments. Sessions less than 30
minutes are not covered. Each group session must contain between 2-20 enrollees.
Follow-Up DSMT
After receiving 10 hours of initial training, an enrollee shall be eligible to receive a maximum of two hours of
follow-up training each year, if ordered. The MCO shall cover additional training for enrollees under age 21 if
determined to be medically necessary and documented in the record.
Follow-up training is based on a 12-month calendar year following completion of the initial training. If an enrollee
completes 10 hours of initial training, the enrollee shall be eligible for two hours of follow-up training for the next
calendar year. If all 10 hours of initial training are not used within the first calendar year, then the enrollee shall
have 12 months to complete the initial training prior to follow up training.
Example #1:
o An enrollee receives his or her first training in April and completes the initial 10 hours by April of
the next year. The enrollee would be eligible for two hours of subsequent training beginning in
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May, since that would be the 13
th
month. If the enrollee completes the two hours of subsequent
training in November of that same year, then additional training cannot begin until January (the
next calendar year).
Example #2:
o An enrollee receives his or her first training in February and exhausts all 10 hours of initial training
by November. The enrollee would be eligible for two hours of subsequent training beginning in
January. If the enrollee completes the two subsequent hours of training by May, then additional
training cannot begin until January of the following year.
Providers are expected to communicate with enrollees to determine if the enrollee has previously received DSMT
services or has exhausted the maximum hours of DSMT services for the given year.
The MCO shall cover 10 hours of initial training (for the first 12 months) and two hours of follow-up training (for
each subsequent year) regardless of the providers of service.
Provider Responsibilities
Providers must ensure the following conditions are met in order to receive MCO reimbursement:
The enrollee meets one of the following requirements:
o Is a newly diagnosed diabetic, gestational diabetic, pregnant with a history of diabetes, or has
received no previous diabetes education;
o Demonstrates poor glycemic control (A1c>7);
o Has documentation of an acute episode of severe hypoglycemia or hyperglycemia occurring in
the past 12 months; or
o Has received a diagnosis of a complication, a diagnosis of a co-morbidity, or prescription for new
equipment such as an insulin pump.
The provider maintains the following documentation requirements:
o A copy of the order for DSMT from the enrollee’s ordering provider;
o A comprehensive plan of care documented in the medical record;
o Start and stop time of services;
o Clinical notes, documenting enrollee progress;
o Original and ongoing pertinent lab work;
o Individual education plan;
o Assessment of the individual’s education needs;
o Evaluation of achievement of self-management goals;
o Proof of correspondence with the ordering provider regarding the enrollee’s progress; and
o All other pertinent documentation.
Enrollee records, facility accreditation, and proof of staff licensure, certification, and educational requirements
must be kept readily available to be furnished, as requested, to Louisiana Medicaid, its authorized representatives,
or the state’s Attorney General’s Medicaid Fraud Control Unit.
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Reimbursement
The MCO shall reimburse for DSMT services based on the Professional Services Fee Schedule, at a minimum. The
following Healthcare Common Procedure Coding System (HCPCS) codes or their successors are used to bill DSMT
services:
G0108-Diabetes outpatient self-management training services, individual, per 30 minutes
G0109-Diabetes self-management training services, group session (two or more) per 30 minutes
NOTE: Services provided to pregnant women with diabetes must be billed with the “TH” modifier.
Early and Periodic Screening, Diagnostic, and Treatment
Preventive Services Program
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program is a comprehensive and preventive
child health program for individuals under the age of 21. The program consists of two mutually supportive,
operational components: (1) ensuring the availability and accessibility of required healthcare services; and (2)
helping Medicaid enrollees and their parents or guardians effectively use these resources. The intent of the EPSDT
program is to direct attention to the importance of preventive health services and early detection and treatment
of identified problems.
Enrollees under 21 years of age are entitled to receive all medically necessary health care, screening, diagnostic
services, treatment, and other measures to correct or improve physical or mental conditions (Section 1905(r)
of the Social Security Act). The EPSDT benefit is comprehensive in nature and includes coverage of all services
described in federal Medicaid statutes and regulations including those that are not covered for adults, not
explicitly described in the Contract, not included in the Medicaid FFS fee schedules, and not covered in the
Louisiana Medicaid State Plan. The MCO shall consult LDH with any questions about these requirements.
The MCO shall have written procedures for EPSDT preventive services in compliance with 42 C.F.R. Part 441
Subpart B-Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), as well as be in compliance with the
Centers for Medicare and Medicaid Services (CMS) State Medicaid Manual, Part 5 – EPSDT. These articles outline
the requirements for EPSDT, including assurance that all EPSDT eligible enrollees are notified of EPSDT available
services; that necessary screening, diagnostic, and treatment services are available and provided; and that
tracking or follow-up occurs to ensure all necessary services were provided to all of the MCO’s enrollees under
the age of 21.
Screening
Enrollee screening includes medical (including developmental, perinatal depression, and behavioral health),
vision, hearing, and dental screenings.
The MCO’s policy shall include the following EPSDT screening guidelines, as age appropriate. The MCO shall ensure
that these guidelines are followed by its providers.
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Periodic Screening
Louisiana Medicaid has adopted the “Recommendations for Preventive Pediatric Health Care” periodicity
schedule promulgated by the American Academy of Pediatrics (AAP)/Bright Futures with two exceptions:
The Louisiana Medicaid EPSDT screening guidelines and policies are for individuals under 21 years of age;
and
Louisiana Medicaid has stricter requirements for lead assessment and blood lead screening in keeping
with LAC 48:V.7005-7009. Based on surveillance data gathered by the State Childhood Lead Poisoning
Prevention Program and review by the state health officer and representatives from medical schools in
the state, all parishes in Louisiana are identified as high risk for lead poisoning.
o The MCO shall ensure children ages six months to 72 months are screened in compliance with
Louisiana Medicaid EPSDT requirements and in accordance with practices consistent with current
Centers for Disease Control and Prevention guidelines, which include the following specifications:
Administer a risk assessment at every well child visit;
Use a blood test to screen all children at ages 12 months and 24 months or at any age
older than 24 months and up to 72 months, if they have not been previously screened;
and
Use a venous blood sample to confirm results when finger stick samples indicate blood
lead levels ≥5 μg/dl (micrograms per deciliter).
o The MCO’s policy must require providers to report a lead case to the Office of Public Health’s
Childhood Lead Poisoning Prevention Program [link
] within 24 working hours. A lead case is
indicated by a blood lead test result of >5 μg/dl.
The AAP Bright Futures “Recommendations for Preventive Pediatric Health Care” can be found on the American
Academy of Pediatrics’ website [link
].
The MCO shall ensure that providers have access to the most current periodicity schedule and that EPSDT
enrollees receive services according to this schedule.
If an abnormality or problem is encountered and treatment is significant enough to require an additional
evaluation and management (E&M) service on the same date, by the same provider, no additional E&M of a level
higher than CPT code 99212 is reimbursable.
The physician, advanced practice registered nurse (APRN), or physician assistant (PA) listed as the rendering
provider must be present and involved during a preventive visit. Any care provided by a registered nurse or other
ancillary staff in a provider’s office is subject to the policy in the “Incident to” Services section of this Manual and
must only be providing services within the scope of their license or certification.
Off-Schedule Screening
If a child misses a regular periodic screening, that child may be screened off-schedule in order to bring the child
up to date at the earliest possible time. However, all screenings performed on children who are under two years
of age must be at least 30 days apart, and those performed on children age two through six years of age must be
at least six months apart.
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Interperiodic Screening
Interperiodic screenings may be performed if medically necessary. The parent/guardian or any medical provider
or qualified health, developmental, or education professional that comes into contact with the child outside the
formal healthcare system may request the interperiodic screening.
An interperiodic screening may only be provided if the enrollee has received an age-appropriate preventive
medical screening. If the preventive screening has not been performed, then the provider must perform an age-
appropriate preventive screening.
An interperiodic screening includes a complete unclothed exam or assessment, health and history update,
measurements, immunizations, health education and other age-appropriate procedures.
An interperiodic screening may be performed and billed for a required Head Start physical or school sports
physical, but must include all of the components required in the EPSDT preventive periodic screening.
Documentation must indicate that all components of the screening were completed. Medically necessary
laboratory, radiology, or other procedures may also be performed and may be billed separately. A well diagnosis
is not required.
Preventive Medical Screening
Components of the EPSDT preventive medical screenings include the following:
A comprehensive health and developmental history (including assessment of both physical and mental
health and development);
A comprehensive unclothed physical exam or assessment;
Appropriate immunizations according to age and health history (unless medically contraindicated or
parents/guardians refuse at the time);
Laboratory tests* (including age-appropriate screenings for newborns, iron deficiency anemia, blood lead
levels, dyslipidemia, and sexually transmitted infections); and
Health education (including anticipatory guidance).
*The blood lead levels and iron deficiency anemia components of the preventive medical screening must be
provided on-site on the same date of service as the screening visit.
The services shall be available both on a regular basis, and whenever additional health treatment or services are
needed. EPSDT screenings may identify problems needing other health treatment or additional services.
Neonatal/Newborn Screening for Genetic Disorders
The MCO shall include in its manuals the directive that providers are responsible for obtaining the results of the
initial neonatal screening by contacting the hospital of birth, the health unit in the parish of the mother’s
residence, or through the Office of Public Health (OPH) Genetics Diseases Program’s web-based Secure Remote
Viewer (SRV) [link
].
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If screening results are not available, or if newborns are screened prior to 24 hours of age, newborns must have
another newborn screen. The newborn infant must be rescreened at the first medical visit after birth, preferably
between one and two weeks of age, but no later than the third week of life.
Initial or repeat neonatal screening results must be documented in the medical record for all children less than six
months of age. Children over six months of age do not need to be screened unless it is medically indicated. When
a positive result is identified from any of the conditions specified in LAC, Book Two of Two: Part V. Preventive
Health Services Subpart 18. Disability Prevention Program Chapter 63. Newborn Heel Stick Screening §6303, and
a private laboratory is used, the provider must immediately notify the Louisiana OPH Genetics Disease Program.
For newborn screening for severe combined immunodeficiency (SCID), the MCO shall cover testing under CPT
code 81479. This code is only to be used for this purpose and until such a time as a permanent procedure code is
in place.
Preventive Vision Screening
Subjective Vision Screening
The subjective vision screening is part of the comprehensive history and physical exam or assessment component
of the medical screening and must include the history of any:
Eye disorders of the child or the child’s family;
Systemic diseases of the child or the child’s family which involve the eyes or affect vision;
Behavior on the part of the child that may indicate the presence or risk of eye problems; and
Medical treatment for any eye condition.
Objective Vision Screening
Objective vision screenings may be performed by trained office staff under the supervision of a licensed physician,
physician assistant, registered nurse, advanced practice registered nurse, or optometrist. The interpretive
conference to discuss findings from the screenings must be performed by a licensed physician, physician assistant,
registered nurse, or advanced practice registered nurse.
Vision screening services are to be provided according to the AAP/Bright Futures recommendations.
Preventive Hearing Screening
Subjective Hearing Screening
The subjective hearing screening is part of the comprehensive history and physical exam or assessment
component of the medical screening and must include the history of:
The child’s response to voices and other auditory stimuli;
Delayed speech development;
Chronic or current otitis media; and
Other health problems that place the child at risk for hearing loss or impairment.
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Objective Hearing Screening
The objective hearing screenings may be performed by trained office staff under the supervision of a licensed
audiologist or speech pathologist, physician, physician assistant, registered nurse, or advanced practice registered
nurse. The interpretive conference to discuss findings from the screenings must be performed by a licensed
physician, physician assistant, registered nurse, or advanced practice registered nurse.
Hearing screening services are to be provided according to the AAP/Bright Futures recommendations.
Dental Screening
An oral health risk assessment must be performed per the Bright Futures periodicity schedule.
Refer to the Dental Services Provider Manual chapter of the Medicaid Services Manual for additional information
pertaining to EPSDT dental services.
Developmental and Autism Screening
The MCO shall cover developmental and autism screenings administered during EPSDT preventive visits in
accordance with the American Academy of Pediatrics (AAP)/Bright Futures periodicity schedule. The MCO shall
also cover developmental and autism screenings performed by primary care providers when administered at
intervals outside EPSDT preventive visits if they are medically indicated for an enrollee at-risk for, or with a
suspected, developmental abnormality. The MCO shall include in its manuals the requirements below.
The MCO will only reimburse the use of age-appropriate, caregiver-completed, and validated screening tools as
recommended by the AAP.
If an enrollee screens positive on a developmental or autism screen, the provider must give appropriate
developmental health recommendations, refer the enrollee for additional evaluation, or both, as clinically
appropriate. Providers must document the screening tool(s) used, the result of the screen, and any action taken,
if needed, in the enrollee’s medical record.
Developmental screening and autism screening are currently reimbursed using the same procedure code.
Providers may only receive reimbursement for one developmental screen and one autism screen per day of
service. To receive reimbursement for both services performed on the same day, providers may submit claims for
2 units of the relevant procedure code.
Perinatal Depression Screening
The MCO shall cover perinatal depression screening administered to an enrollee’s caregiver in accordance with
the American Academy of Pediatrics/Bright Futures periodicity schedule. The screening can be administered from
birth to 1 year during an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) preventive visit,
interperiodic visit, or E&M office visit. This service is a recommended, but not required, component of well-child
care. The MCO shall include in its manuals the requirements below.
Perinatal depression screening must employ one of the following validated screening tools:
Edinburg Postnatal Depression Scale (EPDS)
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Patient Health Questionnaire 9 (PHQ-9)
Patient Health Questionnaire 2 (PHQ-2) and, if positive, a full PHQ-9
Documentation must include the tool used, the results, and any follow-up actions taken. If an enrollee's caregiver
screens positive, the provider must refer the caregiver to available resources, such as their primary care provider,
obstetrician, or mental health professionals, and document the referral. If screening indicates possible suicidality,
concern for the safety of the caregiver or enrollee, or another psychiatric emergency, then referral to emergency
mental health services is required.
Though the screening is administered to the caregiver, the MCO shall reimburse this service under the child’s
Medicaid coverage. If 2 or more children under age 1 present to care on the same day (e.g., twins or other siblings
both under age 1), the provider must submit the claim under only one of the children. When performed on the
same day as a developmental screening, providers must append modifier -59 to claims for perinatal depression
screening.
Immunizations
The MCO shall include in its manuals the requirements below around immunizations. Appropriate immunizations
(unless medically contraindicated or the parents/guardians refuse) are a federally required medical screening
component.
The MCO must ensure that all Medicaid-enrolled providers that provide Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) well child preventive screenings are enrolled in the Vaccines for Children (VFC) program
and utilize VFC vaccines for enrollees aged birth through 18 years of age.
The MCO shall ensure that enrollees receive age appropriate immunizations as described above during their
periodic or interperiodic preventive visit or other appropriate opportunity. The current Childhood Immunization
Schedule recommended by Advisory Committee on Immunizations Practices (ACIP), American Academy of
Pediatrics (AAP), and American Academy of Family Physicians (AAFP), which is updated annually, must be
followed. Providers are responsible for obtaining current copies of the schedule. The MCO shall ensure that
enrollees receive immunizations per the schedule.
NOTE: Refer to the Immunizations section of this Manual for additional information.
Laboratory
The MCO shall include in its manuals the requirements below around laboratory screening. Age-appropriate
laboratory tests are required at selected age intervals. Documented laboratory procedures provided less than six
months prior to the medical screening must not be repeated unless medically necessary. Iron deficiency anemia
and blood lead testing when required are included in the medical screening fee and must not be billed separately.
Diagnosis and Treatment
Screening services are performed to ensure that health problems are found, diagnosed, and treated early before
becoming more serious and additional treatment is necessary. Providers are responsible for identifying any
general suspected conditions and reporting the presence, nature, and status of the suspected conditions.
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The MCO’s policy shall include the following diagnosis and treatment guidelines. The MCO shall ensure that these
guidelines are followed by its providers.
Diagnosis
When a screening indicates the need for further diagnosis or evaluation of a child’s health, the child must receive
a complete diagnostic evaluation within 60 days of the screening or sooner as medically necessary.
The MCO’s policy shall require the provider to make any necessary referrals of the enrollee to a specialist. The
MCO shall maintain a referral system with an adequate provider network to support the provider in making the
referrals and to support the enrollee in accessing the services. It is responsibility of the MCO to ensure that the
enrollee receives the diagnostic services required.
Initial Treatment
Medically necessary health care, initial treatment, or other measures needed to correct or ameliorate physical or
mental illnesses or conditions discovered in a medical, vision, or hearing screening must be initiated within 60
days of the screening or sooner if medically necessary.
Providing or Referring Enrollees for Services
Providers detecting a health or mental health problem in a screening must either provide the services indicated
or refer the enrollee for care. Providers who perform the diagnostic and/or initial treatment services should do so
at the screening appointment when possible, but must ensure that enrollees receive the necessary services within
60 days of the screening or sooner if medically necessary.
Providers who refer the enrollee for care must make the necessary referrals at the time of screening. This
information must be maintained in the enrollee’s record.
The MCO’s policy shall require the provider to make any necessary referrals of the enrollee to a specialist. The
MCO shall maintain a referral system with an adequate provider network to support the provider in making the
referrals and to support the enrollee in accessing the services. It is the responsibility of the MCO to ensure that
the enrollee receives the treatment services required.
Dental Treatment
Fluoride Varnish Application
Fluoride varnish applications are covered when provided in a physician office setting (including RHCs and FQHCs)
once every six months for enrollees six months through five years of age. Providers eligible for reimbursement of
this service include physicians, physician assistants, and nurse practitioners who have reviewed the Smiles for Life
fluoride varnish training module [link
] and successfully completed the post assessment. Physicians are responsible
to provide and document training to their participating staff to ensure competency in fluoride varnish applications.
Fluoride varnish applications may only be applied by the following disciplines:
Appropriate dental providers;
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Physicians;
Physician assistants;
Nurse practitioners;
Registered nurses;
Advanced practice registered nurses;
Licensed practical nurses; or
Certified Medical Assistants.
NOTE: Refer to the Dental Services Provider Manual chapter of the Medicaid Services Manual for information pertaining to
EPSDT Fluoride Varnish Application.
EarlySteps Program
The EarlySteps Program provides services to families with infants and toddlers aged birth to three years who have
a medical condition likely to result in a developmental delay, or who have developmental delays.
The MCO shall ensure that any infant or toddler who meets or may meet the medical or biological eligibility criteria
for EarlySteps (infant and toddler early intervention services) is referred to the local EarlySteps Program.
Additional information about the EarlySteps Program may be found on the LDH webpage [link
].
Eye Care and Vision Services
The MCO shall not require a referral for in-network providers.
The MCO’s requirements for provision and authorization of services within the scope of licensure for optometrists
cannot be more stringent than those requirements for participating ophthalmologists.
Family Planning Services
The MCO shall cover family planning services, including, but not limited to:
Comprehensive medical history and physical exam at least once per year. This visit includes anticipatory
guidance and education related to enrollees’ reproductive health/needs;
Contraceptive counseling to assist enrollees in reaching an informed decision (including natural family
planning, education follow-up visits, and referrals);
Laboratory tests routinely performed as part of an initial or regular follow-up visit/exam for family
planning purposes and management of sexual health;
Drugs for the treatment of lower genital tract and genital skin infections/disorders, and urinary tract
infections, when the infection/disorder is identified/diagnosed during a routine/periodic family planning
visit. A follow-up visit/encounter for the treatment/drugs may also be covered;
Pharmaceutical supplies and devices to prevent conception, including all methods of contraception
approved by the Federal Food and Drug Administration;
Male and female sterilization procedures provided in accordance with 42 C.F.R. Part 441, Subpart F;
Treatment of major complications from certain family planning procedures such as: treatment of
perforated uterus due to intrauterine device insertion; treatment of severe menstrual bleeding caused by
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a medroxyprogesterone acetate injection requiring dilation and curettage; and treatment of surgical or
anesthesia-related complications during a sterilization procedure; and
Transportation services to and from family planning appointments provided all other criteria for Non-
Emergency Medical Transportation (NEMT) are met.
Family planning services shall also include diagnostic evaluation, supplies, devices, and related counseling for the
purpose of voluntarily preventing or delaying pregnancy, detection, or treatment of sexually transmitted
infections (STIs), and age-appropriate vaccination for the prevention of HPV and cervical cancer. Prior
authorization shall not be required for treatment of STIs.
The MCO shall address high STI prevalence by incentivizing providers to conduct screening, prevention education
and early detection, including targeted outreach to at risk populations.
The MCO shall ensure that its enrollees have the freedom to receive family planning services and related supplies
from appropriate Medicaid providers outside the MCO’s provider network without any restrictions, as specified
in 42 C.F.R. § 431.51(b)(2). The out-of-network Medicaid-enrolled family planning services provider shall bill the
MCO and be reimbursed no less than the FFS rate in effect on the date of service.
The MCO shall encourage its enrollees to receive family planning services through the MCO’s network of providers
to ensure continuity and coordination of an enrollee’s total care. No additional reimbursements shall be made to
the MCO for its enrollees who elect to receive family planning services outside the MCO’s provider network.
The MCO shall encourage family planning providers to communicate with the enrollee’s PCP once any form of
medical treatment is undertaken.
The MCO shall maintain accessibility for family planning services through promptness in scheduling appointments
(appointments available within one week).
The MCO shall not provide assisted reproductive technology for treatment of infertility.
Genetic Counseling and Testing
Genetic testing for a particular disease should generally be performed once per lifetime; however, there are rare
instances in which testing may be performed more than once in a lifetime (e.g., previous testing methodology is
inaccurate or a new discovery has added significant relevant mutations for a disease).
Genetic Counseling
The MCO shall require counseling before and after all genetic testing. Counseling must consist of at least all of the
following and be documented in the enrollee’s medical record:
Obtaining a structured family genetic history;
Genetic risk assessment; and
Counseling of the enrollee and family about diagnosis, prognosis, and treatment.
When performed by licensed genetic counselors, the MCO shall reimburse services using the procedure code
specific to genetic counseling. Reimbursement for this service is "incident to" the services of a supervising
physician and is limited to no more than 90 minutes on a single day of service.
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When performed by providers other than licensed genetic counselors, the MCO shall reimburse for counseling
under an applicable evaluation and management code.
Breast and Ovarian Cancer
The MCO shall cover and consider genetic testing for BRCA1 and BRCA2 mutations in cancer-affected individuals
and cancer-unaffected individuals to be medically necessary if the enrollee meets the criteria listed below.
Eligibility Criteria
Individuals meeting one or more of the below criteria are considered eligible.
Individuals with any blood relative with a known BRCA1/BRCA2 mutation;
Individuals meeting the criteria below but with previous limited testing (e.g., single gene and/or absent
deletion duplication analysis) interested in pursuing multi-gene testing;
Individuals with a personal history of cancer, defined as one or more of the following:
o Breast cancer and one or more of the following:
Diagnosed age ≤ 45 years; or
Diagnosed at age 45—50 years with:
• Unknown or limited family history; or
• A second breast cancer diagnosed at any age; or
• ≥ 1 close blood relative* with breast, ovarian, pancreatic, or high-grade (Gleason
score ≥ 7) or intraductal prostate cancer at any age
Diagnosed at age ≤ 60 years with triple negative (ER–, PR–, HER2–) breast cancer;
Diagnosed at any age with:
• Ashkenazi Jewish ancestry; or
• ≥1 close blood relative* with breast cancer at age ≤ 50 years or ovarian,
pancreatic, or metastatic or intraductal prostate cancer at any age; or
• ≥3 total diagnoses of breast cancer in patient and/or close blood relatives*
Diagnosed at any age with male breast cancer; or
Epithelial ovarian cancer (including fallopian tube cancer or peritoneal cancer) at any age;
o Exocrine pancreatic cancer at any age;
o Metastatic or intraductal prostate cancer at any age;
o High-grade (Gleason score ≥ 7) prostate cancer at any age with:
Ashkenazi Jewish ancestry; or
≥1 close blood relative* with breast cancer at age ≤ 50 years or ovarian, pancreatic, or
metastatic or intraductal prostate cancer at any age; or
≥2 close blood relatives* with breast or prostate cancer (any grade) at any age
o A mutation identified on tumor genomic testing that has clinical implications if also identified in
the germline
o To aid in systemic therapy decision-making, such as for HER2-negative metastatic breast cancer
Individuals with a family history of cancer, including unaffected individuals, defined as one or more of the
following:
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o An affected or unaffected individual with a 1
st
- or 2
nd
-degree blood relative meeting any of the
criterion listed above (except individuals who meet criteria only for systemic therapy decision-
making); or
o An affected or unaffected individual who otherwise does not met criteria above but also has a
probability > 5% of a BRCA1/2 pathogenic variant based on prior probability models (e.g., Tyer-
Cuzick, BRCAPro, Pennll)
*For the purpose of familial assessment, close blood relatives include first-, second-, and third-degree relatives on the same
side of the family (maternal or paternal):
1st-degree relatives are parents, siblings, and children;
2nd-degree relatives are grandparents, aunts, uncles, nieces, nephews, grandchildren, and half siblings; or
3rd-degree relatives are great-grandparents, great-aunts, great-uncles, great grandchildren and first cousins.
Familial Adenomatous Polyposis
FAP is caused by a hereditary genetic mutation in the APC tumor suppressor gene which leads to development of
adenomatous colon polyps.
The MCO shall cover and consider genetic testing for adenomatous polyposis coli (APC) gene mutations to
diagnose familial adenomatous polyposis (FAP) to be medically necessary if the enrollee meets the following
criteria.
Eligibility Criteria
Personal history of ≥ 20 cumulative adenoma; or
Known deleterious APC mutation in first-degree family member.
Lynch Syndrome
The MCO shall cover and consider genetic testing for Lynch syndrome to be medically necessary when an enrollee
meets the following criteria:
Amsterdam II criteria; or
Revised Bethesda Guidelines; or
Estimated risk ≥ 5% based on predictive models (MMRpro, PREMM5, or MMRpredict).
Amsterdam II Criteria
There must be at least three relatives with a Lynch Syndrome associated cancer (cancer of the colorectal,
endometrium, small bowel, ureter or renal pelvis) and all of the following criteria should be present:
One must be a first-degree relative to the other two;
Two or more successive generations must be affected;
One or more must be diagnosed before 50 years of age;
Familial adenomatous polyposis should be excluded in the colorectal cancer; and
Tumors must be verified by pathological examination.
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Revised Bethesda Guidelines
One or more criterion must be met:
Colorectal or uterine cancer diagnosed in a patient who is less than 50 years of age;
Presence of synchronous (coexist at the same time), metachronous (previous or recurring) colorectal
cancer, or other Lynch Syndrome associated tumors**;
Colorectal cancer with the MSI-H*** histology**** diagnosed in a patient who is less than 60 years of
age;
Colorectal cancer diagnosed in one or more first-degree relatives with a Lynch syndrome related tumor,
with one of the cancers being diagnosed under 50 years of age; and/or
Colorectal cancer diagnosed in two or more first- or second-degree relatives with Lynch syndrome related
tumors, regardless of age.
**Hereditary nonpolyposis colorectal cancer (HNPCC)-related tumors include colorectal, endometrial, stomach, ovarian,
pancreas, ureter and renal pelvis, biliary tract, and brain (usually glioblastoma as seen in Turcot syndrome) tumors, sebaceous
gland adenomas and keratoacanthomas in Muir-Torre syndrome, and carcinoma of the small bowel.
***MSI-H - microsatellite instability–high in tumors refers to changes in two or more of the five National Cancer Institute-
recommended panels of microsatellite markers
****Presence of tumor infiltrating lymphocytes, Crohn’s-like lymphocytic reaction, mucinous/signet-ring differentiation, or
medullary growth pattern.
Gynecology
Gynecologic services include:
Hysterectomies;
Long-acting reversible contraceptives;
Mammograms;
Pap smears;
Pelvic examinations; and
Saline infusion sonohysterography or hysterosalpingography.
Hysterectomies
Federal regulations governing Medicaid reimbursement of hysterectomies prohibit reimbursement under the
following circumstances:
The hysterectomy is performed solely for the purpose of terminating reproductive capability; or
There is more than one purpose for performing the hysterectomy, but the procedure would not be
performed except for the purpose of rendering the individual permanently incapable of reproducing.
The MCO shall only cover a hysterectomy when:
The person securing authorization to perform the hysterectomy has informed the individual and her
representative (if any), both orally and in writing, that the hysterectomy will make the individual
permanently incapable of reproducing; and
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The individual or their representative (if any) has signed a written acknowledgement of receipt of that
information.
These regulations apply to all hysterectomy procedures, regardless of the enrollee’s age, fertility, or reason for
surgery.
Consent for Hysterectomy
The MCO’s policy for obtaining consent for hysterectomies shall include the following:
The Acknowledgement of Receipt of Hysterectomy Information (hysterectomy consent form)
10
must be
signed and dated by the enrollee on or before the date of the hysterectomy. The consent must include
signed acknowledgement from the enrollee stating the enrollee has been informed orally and in writing
that the hysterectomy will make the enrollee permanently incapable of reproducing. Enrollees who
undergo a covered hysterectomy must complete a hysterectomy consent form but are not required to
complete a sterilization consent form.
The physician who obtains the consent must share the consent form with all providers involved in that
enrollee’s care (e.g., attending physician, hospital, anesthesiologist, and assistant surgeon).
When billing for services that require a hysterectomy consent form, the name on the Medicaid file for the
date of service in which the form was signed should be the same as the name signed at the time consent
was obtained. If the enrollee’s name is different, the provider must attach a letter from the physician’s
office from which the consent was obtained. The letter must be signed by the physician and must state
that the enrollee’s name has changed and must include the enrollee’s social security number and date of
birth. This letter must be attached to all claims requiring consent upon submission for claims processing.
A witness signature is needed on the hysterectomy consent when the enrollee meets one of the following
criteria:
o Enrollee is unable to sign their name and must indicate “x” on the signature line; or
o There is a diagnosis on the claim that indicates mental incapacity.
If a witness signs the consent form, the signature date must match the date of the enrollee’s signature. If
the dates do not match, or the witness does not sign and date the form, claims related to the hysterectomy
will deny.
Exceptions
Obtaining consent for a hysterectomy is unnecessary in the following circumstances:
The individual was already sterile before the hysterectomy, and the physician who performed the
hysterectomy certifies that the individual was already sterile at the time of the hysterectomy and states
the cause of sterility.
The individual required a hysterectomy because of a life-threatening emergency situation in which the
physician determined that prior acknowledgment was not possible, and the physician certifies in his own
10
The current hysterectomy consent form (BHSF Form 96-A), with instructions, is available at www.lamedicaid.com under
the directory link “Forms/Files/Surveys/User Manuals” [link]. The BHSF Form 96-A revised 02/2020 is effective with dates of
service on and after May 1, 2020 and replaces the BHSF Form 96-A revised 05/06. MCOs shall grant providers a grace period
from May 1, 2020 until May 31, 2020, during which either form will be accepted. Effective with dates of service on and after
June 1, 2020, only BHSF Form 96-A revised 02/2020 may be accepted.
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writing that the hysterectomy was performed under these conditions and includes in his narrative a
description of the nature of the emergency.
The individual was retroactively certified for Medicaid benefits, and the physician who performed the
hysterectomy certifies in his own writing that the individual was informed before the operation that the
hysterectomy would make the enrollee permanently incapable of reproducing. In addition, if the
individual was certified retroactively for benefits, and the hysterectomy was performed under one of the
two other conditions listed above, the physician must certify in writing that the hysterectomy was
performed under one of those conditions and that the enrollee was informed, in advance, of the
reproductive consequences of having a hysterectomy.
Reimbursement
Prior to reimbursement, the MCO shall ensure that the hysterectomy consent form or a physician’s written
certification (see Exceptions section) is obtained. The MCO shall allow ancillary providers and hospitals to submit
claims without the hard copy consent. The MCO shall reimburse these providers only if the provider performing
the hysterectomy submitted a valid hysterectomy consent and was reimbursed for the procedure.
The MCO is responsible for maintaining required documentation and shall not shred documentation without prior
approval by LDH.
Long-Acting Reversible Contraceptives
The MCO shall cover the insertion and removal of all FDA approved long-acting reversible contraceptives.
Screening Mammography
The MCO shall cover one screening mammogram per calendar year for females at least 40 years of age.
Papanicolaou Testing for Cervical Cancer
Based on American College of Obstetricians and Gynecologists (ACOG) guidelines regarding Papanicolaou testing
(Pap tests), the MCO shall not routinely cover testing for enrollees under 21 years of age.
Eligibility Criteria (for those under age 21)
The MCO shall consider cervical cancer screening (including repeat screening) medically necessary for enrollees
under 21 years of age if they meet the following criteria:
Were exposed to diethylstilbestrol before birth;
Have human immunodeficiency virus;
Have a weakened immune system;
Have a history of cervical cancer or abnormal cervical cancer screening test; or
Meet other criteria subsequently published by ACOG.
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Reimbursement
The MCO shall include the collection of cytopathologic vaginal test (Pap test) specimens in the reimbursement of
the evaluation and management services.
For those enrollees under the age of 21, the MCO shall require the treating provider to submit the required
documentation needed for billing to the laboratory provider.
Pelvic Examinations
The MCO shall cover routine pelvic examinations in the reimbursement for the evaluation and management
service. Therefore, the MCO shall not allow routine pelvic examinations to be billed as separate procedures.
Pelvic examinations under anesthesia may be medically necessary for certain populations. The MCO shall require
the provider to indicate the medical justification for the pelvic examination under anesthesia in the enrollee’s
medical record.
Saline Infusion Sonohysterography or Hysterosalpingography
The MCO shall cover saline infusion sonohysterography or hysterosalpingography, limited to the assessment of
fallopian tube occlusion or ligation following a sterilization procedure.
Home Health Services
A home health agency (HHA) provides patient care services in the enrollee’s residential setting, under the order
of a physician, that are necessary for the diagnosis and treatment of the enrollee’s illness or injury. Such services
include part-time skilled nursing services, extended skilled nursing services (for enrollees under 21 years of age),
home health aide services, physical therapy (PT), speech therapy (ST), occupational therapy (OT), and medical
supplies recommended by the physician as required in the care of the enrollee and suitable for use in any setting
in which normal life activities take place.
The MCO shall cover the following home health services:
Skilled nursing (intermittent or part-time);
Home health aide services, in accordance with the plan of care (POC) as recommended by the attending
physician;
Extended skilled nursing services (also referred to as extended home health), as part of Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) services, is extended nursing care by a registered nurse or
a licensed practical nurse (LPN) and may be provided to enrollees under age 21 who are considered
“medically fragile”;
Rehabilitation services are physical, occupational and speech therapies, including audiology services; and
Medical supplies, equipment, and appliances, as recommended by the physician, required in the POC for
the enrollee and suitable for use in any setting in which normal life activities take place are covered under
the Durable Medical Equipment (DME) program and must be prior authorized.
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The MCO shall ensure that a face-to-face encounter between the patient and the physician or an allowed non-
physician provider (NPP) occur no more than 90 days prior to, or 30 days after, admission to the home health
agency.
Hyperbaric Oxygen Therapy
The MCO shall cover hyperbaric oxygen therapy treatments administered in a hyperbaric oxygen therapy chamber
for the following conditions, if deemed medically necessary:
Acute carbon monoxide intoxication;
Decompression illness;
Gas embolism;
Gas gangrene;
Acute traumatic peripheral ischemia. Hyperbaric oxygen therapy is a valuable adjunctive treatment to be
used in combination with accepted standard therapeutic measures when loss of function, limb, or life is
threatened;
Crush injuries and suturing of severed limbs. Hyperbaric oxygen therapy would be an adjunctive treatment
when loss of function, limb, or life is threatened;
Progressive necrotizing infections (necrotizing fasciitis);
Acute peripheral arterial insufficiency;
Preparation and preservation of compromised skin grafts (not for primary management of wounds);
Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management;
Osteoradionecrosis as an adjunct to conventional treatment;
Soft tissue radionecrosis as an adjunct to conventional treatment;
Cyanide poisoning;
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to
antibiotics and surgical treatment; and
Diabetic wounds of the lower extremities when:
o The wound is classified as Wagner grade 3 or higher; and
o An adequate course of standard wound therapy was not sufficient to lead to healing.
Immunizations
For enrollees age 18 and younger, the MCO shall only cover vaccine administration for immunizations
recommended by the Advisory Committee on Immunization practices (ACIP). Vaccines for enrollees age 18 and
younger are provided free of charge through the Louisiana Immunization Program/Vaccines for Children program,
as described below.
For enrollees age 19 and older, the MCO shall cover all ACIP-recommended vaccines, and vaccine administration,
according to ACIP recommendations and without restrictions or prior authorization.
NOTE: Refer to the EPSDT Preventive Services Program section of this Manual for additional information.
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Combination Vaccines
The MCO shall encourage combination vaccines in order to maximize the opportunity to immunize and to reduce
the number of injections a child receives in one day. The MCO shall not reimburse providers for a single-antigen
vaccine and its administration if a combined-antigen vaccine is medically appropriate and the combined vaccine
is approved by the Secretary of the U.S. Department of Health and Human Services.
Louisiana Immunization Program/Vaccines for Children Program
The MCO must ensure that all Medicaid-enrolled providers that provide Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) well child preventive screenings are enrolled in the Vaccines for Children (VFC) program
and utilize VFC vaccines for enrollees aged birth through 18 years of age.
Providers can obtain a VFC enrollment packet by calling the Office of Public Health’s (OPH) Immunization Section
[link
] at (504) 568-2600.
Reimbursement
The MCO shall require providers to indicate the CPT code for the specific vaccine in addition to the appropriate
administration CPT code(s) to receive reimbursement for the administration of appropriate immunizations. The
listing of the vaccine on the claim form is required for federal reporting purposes.
Vaccines from the Vaccines for Children Program are available at no cost to the provider and are required to be
used for Medicaid enrollees through 18 years of age. Therefore, the MCO shall reimburse CPT codes for vaccines
available from the VFC Program at zero ($0) for every enrollee from birth through 18 years of age.
Declared Pediatric Flu Vaccine Shortage Plan
The MCO’s policy shall include the following provisions regarding flu vaccine shortages:
If a Medicaid provider does not have the VFC pediatric influenza vaccine on hand to vaccinate a high
priority Medicaid-enrolled child, the provider should not turn away, refer or reschedule the enrollee for
a later date if the vaccine is available from private stock. The provider should use pediatric influenza
vaccine from private stock and replace the dose(s) used from private stock with dose(s) from VFC stock
when the VFC vaccine becomes available.
If a Medicaid provider does not have the VFC pediatric influenza vaccine on hand to vaccinate a non-high
priority or non-high risk Medicaid-enrolled child, the enrollee can:
o Wait for the VFC influenza vaccine to be obtained, or
o If the enrollee chooses not to wait for the VFC influenza vaccine to be obtained, and the provider
has private stock of the vaccine on hand, the MCO shall reimburse only the administration of the
private stock vaccine.
If the provider intends to charge the enrollee for the vaccine, then prior to the injection,
the provider shall inform the enrollee/guardian that the actual vaccine does not come
from the VFC program and the enrollee will be responsible for the cost of the vaccine. In
these situations, the provider shall obtain signed documentation that the enrollee is
responsible for reimbursement of the vaccine only.
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Louisiana Immunization Network (LINKS)
Louisiana Immunization Network (LINKS) is a computer-based system designed to track immunization records for
providers and their patients by:
Consolidating immunization information among all healthcare providers,
Assuring adequate immunization coverage levels, and
Avoiding duplicative immunizations.
The MCO should access LINKS directly to obtain immunization reports. LINKS can be accessed through the OPH
website [link
].
The MCO shall ensure that providers report the required immunization data into LINKS.
“Incident to” Services
“Incident to” services means services or supplies that are furnished as an integral, although incidental, part of a
supervising provider’s professional services. For physicians, “incident to” services include those provided by
auxiliary personnel (e.g., medical assistants, licensed practical nurses, registered nurses, etc.), but exclude those
provided by an advanced practice registered nurse (APRN) and physician assistant (PA). For APRNs and PAs,
“incident to” services also include those provided by auxiliary personnel. For all “incident to” services, auxiliary
personnel must only operate within the scope of practice of their license or certification.
Provider supervision must consist of either personal participation in the service or direct supervision coupled with
review and approval of the service notes. Direct supervision is defined as the provider being present in the facility,
though not necessarily present in the room where the service is being rendered, and immediately available to
provide assistance and direction throughout the time the service is performed. For Office of Public Health clinics
and services provided by community health workers (CHWs), providers must furnish general supervision, defined
as under the supervising provider’s overall direction and control, but the provider’s presence is not required in
the facility during the performance of the service.
When an APRN or PA provides all parts of the service independent of a supervising or collaborating physician’s
involvement, even if a physician signs off on the service or is present in the facility, the service does not meet the
requirements of “incident to” services. Instead, claims for such services must be submitted using the APRN or PA
as the rendering provider.
It is inappropriate for a physician to submit claims for services provided by an APRN or PA with the physician listed
as the rendering provider when the physician is only supervising, reviewing, or “signing off” on the APRN’s or PA’s
records. Services billed in this manner are subject to post-payment review, recoupment, and additional sanctions
as deemed appropriate by Louisiana Medicaid.
Institutional Long-Term Care Facilities/Nursing Homes
The MCO is responsible for all covered services, including periods in which the enrollee is admitted to a long-term
care facility/nursing home for rehabilitative purposes, with the exception of non-emergency, non-ambulance
transportation services (see Medical Transportation section), and prior to the time the member is disenrolled from
the MCO.
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Intrathecal Baclofen Therapy
The MCO shall cover surgical implantation of a programmable infusion pump for the delivery of intrathecal
baclofen (ITB) therapy for individuals four years of age and older who meet medical necessity for the treatment
of severe spasticity of the spinal cord or of cerebral origin.
The following diagnoses are considered appropriate for ITB treatment and infusion pump implantation:
Meningitis;
Encephalitis;
Dystonia;
Multiple sclerosis;
Spastic hemiplegia;
Infantile cerebral palsy;
Other specified paralytic syndromes;
Acute, but ill-defined, cerebrovascular disease;
Closed fracture of the base of skull;
Open fracture of base of skull;
Closed skull fracture;
Fracture of vertebral column with spinal cord injury;
Intracranial injury of other and unspecified nature; or
Spinal cord injury without evidence of spinal bone injury.
Criteria for Enrollee Selection
Implantation of an ITB infusion pump is considered medically necessary, when the candidate is four years of age
or older with a body mass sufficient to support the implanted system, and one or more of the following criteria is
met:
Inclusive Criteria for Candidates with Spasticity of Cerebral Origin
o There is severe spasticity of cerebral origin with no more than mild athetosis;
o The injury is older than one year;
o There has been a drop in Ashworth scale of 1 or more;
o Spasticity of cerebral origin is resistant to conservative management; or
o The candidate has a positive response to test dose of ITB.
Inclusive Criteria for Candidates with Spasticity of Spinal Cord Origin
o Spasticity of spinal cord origin that is resistant to oral antispasmodics or side effects unacceptable
in effective doses;
o There has been a drop in Ashworth scale of 2 or more; or
o The candidate has a positive response to test dose of intrathecal baclofen.
Caution should be exercised when considering ITB infusion pump implantation for candidates who:
Have a history of autonomic dysreflexia;
Suffer from psychotic disorders;
Have other implanted devices; or
MCO Manual | SERVICES | Professional Services 159
Utilize spasticity to increase function such as posture, balance, and locomotion.
Exclusion Criteria for Candidates
Consideration shall not be made if the candidate:
Fails to meet any of the inclusion criteria;
Is pregnant, or refuses or fails to use adequate methods of birth control;
Has a severely impaired renal or hepatic function;
Has a traumatic brain injury of less than one year pre-existent to the date of the screening dose;
Has history of hypersensitivity to oral baclofen;
Has a systematic or localized infection which could infect the implanted pump; or
Does not respond positively to a 50, 75, or 100 mcg intrathecal bolus of baclofen during the screening trial
procedure.
The MCO shall cover outpatient bolus injections given to candidates for the ITB infusion treatment if medically
necessary even if the enrollee fails the screening trial procedure.
LSU Enhanced Professional Service Fees
LSU professional service providers receive an enhanced fee for certain codes. The only codes that are to be paid
at these enhanced rates are those specific code and specific type of service combinations that are listed on the
LSU Enhanced Professional Services Fee Schedules.
If the code and the type of service code are not listed on the enhanced fee schedules, then the minimum rate
reimbursed to these LSU providers would be based on the Louisiana Medicaid Professional Services Fee Schedule.
There are two different LSU reimbursement groups:
Group 1: LSU Essential Provider – Shreveport. This group includes providers:
o # 2430769, NPI 1013374222, TAX ID 364774713
Group 2: LSU Essential Provider – New Orleans. This group includes providers:
o # 1038296, NPI 1992975775, TAX ID 261531455
o # 1940046, NPI 1558303420, TAX ID 726000749
o # 1167347, NPI 1477582526, TAX ID 721304948
o # 1169269, NPI 1477582526, TAX ID 721304948
o # 1177130, NPI 1932492626, TAX ID 452297609
o # 1945846, NPI 1477582526, TAX ID 721304948
o # 2436473, NPI 1275984973, TAX ID 812574422
o # 2518755, NPI 1285285510, TAX ID 841945250
Each reimbursement group has its own special reimbursement assigned which is outlined on the LSU Enhanced
Professional Services Fee Schedules.
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Modifiers
The modifiers in the table in this section indicate modifiers that impact reimbursement or policy to establish
minimum reimbursement amounts. The below is an exclusive list of modifiers allowed for the purposes of
establishing minimum reimbursement rates. The MCO may not mandate the use of modifiers that result in a
reimbursement rate that is below the rate established by the fee schedules and these allowed modifiers.
Modifier
Use/Example
Special Billing Instructions
Minimum Reimbursement
22
Unusual Service
Service provided is greater
than that which is usually
required (e.g., delivery of
twins); not to be used with
visits or lab codes
125% of the fee on file or
billed charges whichever is
lower
24
Unrelated evaluation
and management
service by the same
physician during the
post-op period
Lower of billed charges or fee
on file
25
Significant, separately
identifiable
evaluation and
management service
by the same physician
on the same day of a
procedure or other
service
When a suspected condition
identified during a screening visit
and diagnosed/treated by the
screening provider during the
same visit, only lower level E&M
appended with modifier 25
allowable; otherwise claim will
deny
Improper use of modifiers to
maximize reimbursement and to
bypass valid claims editing will
subject the provider to
administrative sanctions and/or
possible exclusi
on from the
Louisiana Medicaid program.
Lower of billed charges or fee
on file
26
Professional
Component
Professional portion only of
a procedure that typically
consists of both a
professional and a technical
component (e.g.,
interpretation of laboratory
or x-
ray procedures
performed by another
provider)
Lower of billed charges or
40% of the fee on file
TC
Technical Component
MCOs may not reimburse the
technical component only on
laboratory and radiology claims.
Reimbursement is not allowed for
both the professional component
and full service on the same
procedure.
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50
Bilateral Procedure
Lower of billed charges or
150% of the fee on file
51
Multiple Procedures
Lower of billed charges or
100% of the fee on file for
primary/ 50% of the fee on
file for all others
52
Reduced Services
Lower of billed charges or
75% of the fee on file
53
Discontinued
Procedure
Only for use by Free
Standing Birthing Centers
(FSBC’s) when the enrollee is
transferred prior to delivery
50% of the FSBC’s facility fee
or billed charges, whichever
is lower
54
Surgical Care Only
Surgical procedure
performed by physician
when another physician
provides pre- and/or
postoperative management
Lower of billed charges or
70% of the fee on file
55
Postoperative
Management Only
Postoperative management
only when another physician
has performed the surgical
procedure
Lower of billed charges or
20% of the fee on file
56
Preoperative
Management Only
Preoperative management
only when another physician
has performed the surgical
procedure
Lower of billed charges or
10% of the fee on file
NOTE: If full service payment is made for a procedure (i.e., the procedure is billed and paid with no modifier), additional
payment will not be made for the same procedure for surgical care only, post-operative care only, or preoperative care only.
In order for all providers to be paid in the case when modifiers -54, -55, and -56 would be used, each provider must use the
appropriate modifier to indicate the service performed. Claims that are incorrectly billed and paid must be adjusted using the
correct modifier in order to allow payment of other claims billed with the correct modifier.
57
Evaluation and
management service
resulting in the initial
decision to perform
the surgery
Lower of billed charges or fee
on file
59
Distinct procedural
services performed;
separate from other
services rendered on
the same day by the
same provider
Improper use of modifiers to
maximize reimbursement and to
bypass valid claims editing will
subject the prov
ider to
administrative sanctions and/or
possible exclusion from the
Louisiana Medicaid program.
Lower of billed charges or fee
on file
62
Two Surgeons
Lower of billed charges or
80% of the fee on file for each
surgeon.
63
Infants less than 4 kg
Lower of billed charges or
125% of the fee on file
66
Surgical Team
Performance of highly
complex procedure
requiring the concomitant
services of several
Documentation must clearly
indicate the name of each
surgeon and the procedures
performed by each.
Lower of billed charges or
80% of the fee on file for each
surgeon.
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physicians (e.g., organ
transplant)
NOTE: In order for correct payment to be made in the case of two surgeons or a surgical team, all providers involved must
bill correctly using appropriate modifiers. If full service payment is made for a procedure (i.e., the procedure is billed and paid
with no modifier), additional payment will not be made for the same procedure for two surgeons or surgical team. Payment
will not be made for any procedure billed for both full service (no modifier) and for two surgeons or surgical team. If even one
of the surgeons involved bills with no modifier and is paid, no additional payment will be made to any other surgeon for the
same procedure. Claims which are incorrectly billed with no modifier and are paid must be adjusted using the correct modifier
in order to allow payment of other claims billed with the correct modifier.
79
Unrelated procedure
or service by the same
physician during the
postoperative period
Lower of billed charges or fee
on file
80
Assistant Surgeon
(MD)
Lower of billed charges or:
MD’s - 20% of the full service
physician fee on file.
AS
Assistant at Surgery
(Physician Assistant or
APRN)
Lower of billed charges or
80% of MD’s ‘Assistant
Surgeon’ fee
NOTE: *The list of codes acceptable with the 80/AS modifier is posted on the Louisiana Medicaid website.
AT
Acute Treatment
Chiropractors use this
modifier
Lower of billed charges or fee
on file
95
Telemedicine
Services provided via a
telecommunications
system, see the
Telemedicine/Telehealth
section
Modifier shall be
appended to claims for all
services provided via
telemedicine/telehealth
Lower of billed charges or
100% of the fee on file
Q5
Reciprocal Billing
Arrangement
Services provided by a
substitute physician on an
occasional reciprocal basis
not over a continuous period
of longer than 60 days. Does
not apply to substitution
within the same group.
The regular physician submits the
claim and receives
reimburse
ment for the
substitu
te. The record must
identify each service provided by
the substitute.
Lower of billed charges or
100% of the fee on file
Q6
Locum Tenens
Services provided by a
substitute physician
retained to take over a
regular physician’s practice
for reasons such as illness,
pregnancy, vacation, or
continuing education. The
substitute is an independent
contractor typically paid on
a per diem or fee-for- time
basis and does not provide
services over a period of
longer than 60 days.
The regular physician submits
claims
and receives
reimburse
ment for the
substitute. The record must
identify each service provided by
the substitute
Lower of billed charges or
100% of the fee on file
TH
Prenatal Services
Lower of billed charges or fee
for prenatal services
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QW
Laboratory
Required when billing
certain laboratory codes
Lower of billed charges or fee
on file
Site Specific Modifiers
Unless specifically indicated otherwise in CPT, providers should use site-specific modifiers to accurately document
the anatomic site where procedures are performed when appropriate for the clinical situation.
E1
Upper left, eyelid Lower left, eyelid
LT*
Left side
E2
Upper right, eyelid
RT*
Right side
E3
Lower right, eyelid
LC
Left circumflex, coronary artery
E4
Left hand, thumb
RC
Right coronary artery
FA
Left hand, second digit
LD
Left anterior descending coronary artery
F1
Left hand, third digit
TA
Left foot, great toe
F2
Left hand, fourth digit
T1
Left foot, second digit
F3
Left hand, fifth digit
T2
Left foot, third digit
F4
Right hand, thumb
T3
Left foot, fourth digit
F5
Right hand, second digit
T4
Left foot, fifth digit
F6
Right hand, third digit
T5
Right foot, great toe
F7
Right hand, fourth digit
T6
Right foot, second digit
F8
Right hand, fifth digit
T7
Right foot, third digit
F9
Upper left, eyelid Lower left, eyelid
T8
Right foot, fourth digit
T9
Right foot, fifth digit
* When “bilateral” is part of the procedure code description, RT/LT or -50 shall not be used.
Multiple Surgical Reduction Reimbursement
Multiple surgery reduction is the general industry term applied to the practice of reimbursing decreasing pay
percentages for multiple surgeries performed during the same surgical session. When more than one surgical
procedure is submitted for a patient on the same date of service, the 51 modifier is to be appended to the
secondary code(s). Certain procedure codes are exempt from this process due to their status as “add-on” or
“modifier 51 exempt” codes as defined in CPT.
Secondary Bilateral Surgical Procedures
Multiple modifiers may be appended to secondary surgical procedure codes when appropriate. Billing multiple
surgical procedures and bilateral procedures during the same surgical session should follow Medicaid policy for
each type of modifier.
Bilateral secondary procedures are submitted with modifiers 50/51 and at a minimum be reimbursed at 75% of
the Medicaid allowable fee or the submitted charges, whichever is lowest.
Newborn Care and Discharge
The appropriate CPT codes for the initial care of the normal newborn may be paid when the service provided
meets the criteria as defined by CPT. This service is limited to once per lifetime of the enrollee.
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The CPT code for subsequent care of the normal newborn may be paid for each day care is rendered subsequent
to the date of birth, other than the discharge date. The MCO shall cover up to three normal newborn subsequent
care days.
NOTE: Refer to the Hospital Services section for hospital billing of newborn care.
Circumcisions
The MCO shall cover all medically necessary circumcisions.
Routine circumcision is an approved MCO value-added benefit.
Discharge Services
The MCO’s policy for discharge services shall include the following:
When the date of discharge is subsequent to the admission date, the provider shall submit claims for
newborn hospital discharge services using the appropriate CPT code for hospital day management code.
When newborns are admitted and discharged on the same date, the provider shall use the appropriate
code for these services.
Newborn Screenings for Genetic Disorders
Newborn screening includes testing for certain specified conditions recommended by the American College of
Medical Genetics. The MCO’s policy shall include that La. R.S. 40:1081.1 and 40:1081.2 require hospitals with
delivery units to screen all newborns before discharge regardless of the newborn’s length of stay at the hospital.
The Louisiana Administrative Code Title 48, Part V, Subpart 18, Chapter 63 provides the requirements related to
newborn screenings.
NOTE: Refer to the EPSDT Preventive Services Program section for additional information on obtaining the results of newborn
screenings for genetic disorders.
Neonatal/Pediatric Critical Care Billing
The MCO shall configure its claims processing systems, with regard to the billing of initial/subsequent neonatal
and pediatric critical care and initial and continuing intensive care services, as follows:
The claims billed with these codes will be configured to pay based on provider specialty.
The provider specialties listed below will be configured to pay with these codes:
o Neonatologist
o Pediatric Intensivist
Any other provider specialty that bills this set of codes will deny or pend. The MCO shall require the
provider to follow the appropriate MCO reconsideration process.
Obstetrics
The MCO shall require that all prenatal outpatient visit evaluation and management (E&M) procedure codes be
modified with TH. The TH modifier is not required for observation or inpatient hospital physician services.
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Initial Prenatal Visit(s)
The MCO shall cover two initial prenatal visits per pregnancy (270 days). These two visits may not be performed
by the same attending provider.
The MCO shall consider the enrollee a ‘new patient’ for each pregnancy whether or not the enrollee is a new or
established patient to the provider/practice. The MCO shall require that the appropriate level E&M CPT procedure
code be billed for the initial prenatal visit with the TH modifier. A pregnancy-related diagnosis code must also be
used on the claim form as either the primary or secondary diagnosis.
Reimbursement for the initial prenatal visit, which must be modified with TH, shall include, but is not limited to,
the following:
Estimation of gestational age by ultrasound or firm last menstrual period. (If the ultrasound is performed
during the initial visit, it may be billed separately. Also, see the ultrasound policy below.);
Identification of patient at risk for complications including those with prior preterm birth;
Health and nutrition counseling; and
Routine dipstick urinalysis.
If the pregnancy is not verified, or if the pregnancy test is negative, the service may only be submitted with the
appropriate level E&M without the TH modifier.
The MCO may require notification by the provider of obstetrical care at the time of the first visit of the pregnancy.
Follow-Up Prenatal Visits
The MCO shall require the provider to submit the appropriate level E&M CPT code from the range of procedure
codes used for an established patient for the subsequent prenatal visit(s). The E&M CPT code for each of these
visits must be modified with the TH modifier.
The reimbursement for this service shall include, but is not limited to:
The obstetrical (OB) examination;
Routine fetal monitoring (excluding fetal non-stress testing);
Diagnosis and treatment of conditions both related and unrelated to the pregnancy; and
Routine dipstick urinalysis.
Delivery Codes
The MCO’s policy for coding deliveries shall include the following:
The most appropriate “delivery only” CPT code shall be submitted. Delivery codes inclusive of the
antepartum care and/or postpartum visit are not covered except in cases related to third party liability.
Modifier -22 for unusual circumstances is to be used with the most appropriate CPT code for a vaginal or
cesarean section delivery when the method of delivery is the same for all births.
If the multiple gestation results in a cesarean section delivery and a vaginal delivery, the provider must
use the most appropriate “delivery only” CPT code for the cesarean section delivery and also bill the most
appropriate vaginal “delivery only” procedure code with modifier -51 appended.
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When a long-acting reversible contraceptive (LARC) is inserted immediately postpartum and prior to
discharge, reimbursement shall be made separately for the insertion procedure and the LARC.
Global Maternity Care for Third Party Liability
Global maternity care includes pregnancy-related antepartum care, admission to labor and delivery, management
of labor including fetal monitoring, delivery, and uncomplicated postpartum care. Other antepartum services are
not considered part of global maternity services—they are reimbursed separately. An initial visit, confirming the
pregnancy, is not a part of global maternity care services.
The MCO shall accept global maternity procedure codes for claims billed for secondary payment. Global maternity
codes shall be recognized and considered for reimbursement only when billed to the MCO as secondary payer.
The MCO shall deny claims billed to the MCO as primary payer. Refer to the Professional Services Fee Schedule
for the global maternity procedure codes and rates.
The MCO shall calculate reimbursement based upon LDH TPL payment policy as defined in the Contract or this
Manual.
LDH, or is contracted actuary, will consider maternity global codes in rate development. Global maternity codes
shall only be payable when billed to the MCO as secondary payer; therefore, these codes will not be included in
encounter kick payment logic.
The provider should bill prenatal, delivery, and/or postpartum services separately when the enrollee’s coverage
terminates prior to delivery.
Add-on codes for maternity-related anesthesia will not apply. The MCO should bypass add-on rates when
modifiers 47 and 52 are reported.
Interest applies when a payable clean claim remains unpaid beyond the 30 day claims processing deadline. Refer
to the Contract for detailed information.
Maternity claims where the enrollee’s primary carrier does not cover maternity services should be billed to the
MCO as primary payer. The MCO should accept global maternity procedure codes for claims billed only as
secondary payer.
Postpartum Care Visit
The postpartum care CPT code (which is not modified with –TH) shall be reimbursed for the postpartum care visit
when performed. Reimbursement is allowed for one postpartum visit per 270 days.
The reimbursement for the postpartum care visit includes, but is not limited to:
Physical examination;
Body mass index (BMI) assessment and blood pressure check;
Routine dipstick urinalysis;
Follow up plan for women with gestational diabetes;
Family planning counseling;
Breast feeding support including referral to the Special Supplemental Nutrition Program for Women,
Infants and Children (WIC), if needed;
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Screening for postpartum depression and intimate partner violence; and
Other counseling and or services associated with releasing a patient from obstetrical care.
Prenatal Laboratory and Ultrasound Services
Prenatal Lab Panels
The MCO shall cover the obstetric panel test as defined by CPT only once per pregnancy.
The MCO shall cover a complete urinalysis only once per pregnancy (270 days) per billing provider, or more when
medically necessary, for example, to diagnose a disease or infection of the genitourinary tract.
Non-Invasive Prenatal Testing
Non-Invasive Prenatal Testing (NIPT) is a genetic test which uses maternal blood that contains cell-free fetal
deoxyribonucleic acid (DNA) from the placenta. NIPT is completed during the pre-natal period of pregnancy to
screen for the presence of some common fetal chromosomal abnormalities. Common types of chromosomal
abnormalities (aneuploidies and microdeletions) in fetuses include:
Trisomy 21 (Down syndrome);
Trisomy 18 (Edwards syndrome); and
Trisomy 13 (Patau syndrome).
The MCO shall cover NIPT when medically necessary and without the requirement of prior authorization.
NIPT is considered medically necessary once per pregnancy for pregnant women over the age of 35, and for
women of all ages who meet one or more of the following high-risk criteria:
Abnormal first trimester screen, quad screen or integrated screen;
Abnormal fetal ultrasound scan indicating increased risk of aneuploidy;
Prior family history of aneuploidy in first (1
st
) degree relative
11
for either parent;
Previous history of pregnancy with aneuploidy; and
Known Robertsonian translocation in either parent involving chromosomes 13 or 21.
The MCO shall not cover NIPT for women with multiple gestations.
Ultrasounds
A minimum of three obstetric ultrasounds shall be reimbursed per pregnancy (270 days) without the requirement
of prior authorization or medical review when performed by providers other than maternal fetal medicine
specialists:
When an obstetric ultrasound is performed for an individual with multiple gestations, leading to more
than one procedure code being submitted, this shall only be counted as one obstetric ultrasound; and
11
1
st
degree relative is defined as a person’s parent, child, or sibling.
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Obstetric ultrasounds performed in inpatient hospital, emergency department, and labor and delivery
triage settings are excluded from this count.
For maternal fetal medicine specialists, there shall be no prior authorization or medical review required for
reimbursement of obstetric ultrasounds. In addition, reimbursement for CPT codes 76811 and 76812 is restricted
to maternal fetal medicine specialists. In all cases, obstetric ultrasounds must be medically necessary to be eligible
for reimbursement.
Fetal Non-Stress Test
The MCO shall cover fetal non-stress tests when medically necessary as determined by meeting one of the
following criteria:
The pregnancy is post-date/post-maturity (after 41 weeks gestation);
The treating provider suspects potential fetal problems in an otherwise normal pregnancy; or
The pregnancy is high risk, including but not limited to diabetes mellitus, pre-eclampsia, eclampsia,
multiple gestations, and previous intrauterine fetal death.
Fetal Biophysical Profile
The MCO shall cover fetal biophysical profiles when medically necessary, as determined by meeting at least two
of the following criteria:
Gestation period is at least 28 weeks
Pregnancy must be high-risk, and if so, the diagnosis should reflect high risk
Uteroplacental insufficiency must be suspected in a normal pregnancy
Tobacco Cessation Counseling During Pregnancy
The MCO shall cover tobacco cessation counseling for pregnant enrollees when provided by the enrollee’s PCP or
OB provider. Tobacco cessation counseling may be provided by other appropriate healthcare professionals upon
referral from the enrollee’s PCP or OB provider, but all care must be coordinated.
During the prenatal period through 60 days postpartum, the MCO shall cover up to four tobacco cessation
counseling sessions per quit attempt, up to two quit attempts per calendar year, for a maximum of eight
counseling sessions per calendar year. These limits may be exceeded if deemed medically necessary.
Minimum reimbursement for tobacco cessation counseling shall be based on the applicable current procedural
terminology (CPT) code on the Professional Services Fee Schedule and must be supported by appropriate
documentation. The MCO shall require the -TH modifier to be included on claims for tobacco cessation counseling
within the prenatal period. The -TH modifier is not to be used for services in the postpartum period.
If tobacco cessation counseling is provided as a significant and separately identifiable service on the same day as
an E&M visit and is supported by clinical documentation, a modifier to indicate a separate service may be used,
when applicable.
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Remote Patient Monitoring
Remote patient monitoring is the use of medical devices to measure and transmit health data from an enrollee to
a provider, who can then analyze the data to make treatment recommendations. The MCO may cover remote
patient monitoring for the management of hypertension and diabetes for pregnant enrollees.
Organ Transplants
The MCO shall cover medically necessary organ transplants when performed in a hospital that is a Medicare
approved transplant center for that procedure.
Physician Administered Medication
The MCO shall cover medically necessary physician-administered medications that are reimbursable in Louisiana
Medicaid. For those medications that are on the Louisiana Medicaid FFS fee schedules, the MCO shall also cover
them in the medical benefit. The MCO may also elect to cover these medications in the pharmacy benefit. For
those medications that are not on the Louisiana Medicaid FFS fee schedules, the MCO may cover them in either
the medical benefit, the pharmacy benefit, or both.
Physician administered medication that are included on the PDL shall have the same preferred status and prior
authorization criteria as the PDL, even when billed and paid as a medical benefit (except Antiemetic/Antivertigo
Agents therapeutic class).
At a minimum, administration of the medication may be billed using the lowest level office visit (CPT procedure
code 99211) if a higher-level evaluation and management visit has not been submitted for that date by the
rendering provider. Any alternative reimbursement for medication administration must be equivalent to or
greater than the reimbursement for CPT code 99211.
The MCO shall apply edits for physician-administered drugs, updated quarterly, based on the CMS NDC-HCPCS
Crosswalk file.
Physician Assistants
Unless otherwise excluded by Louisiana Medicaid, the services rendered by physician assistants shall be
determined by individual licensure, scope of practice, and supervising physician delegation. The supervising
physician must be an enrolled Medicaid provider. Clinical practice guidelines and protocols shall be available for
review upon request by authorized representatives of Louisiana Medicaid and contracted MCOs.
Immunizations, physician-administered drugs, long-acting reversible contraceptives, and Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) medical, vision, and hearing screens are reimbursed at a minimum
of 100% of the physician fee on file. All other reimbursable procedures are reimbursed at a minimum of 80% of
the physician fee on file.
Physician assistants must obtain an individual Medicaid provider number and, when the rendering provider, must
bill under this provider number for services rendered.
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Preventive Services for Adults
The MCO shall cover all United States Preventive Services Task Force Grade A and B preventive services for adults
age 21 years and older without restrictions or prior authorization. In addition, the MCO shall cover one preventive
medicine E&M service for adults aged 21 years and older per calendar year.
The MCO’s policy for preventive medicine E&M services shall include the following:
Providers are to use the appropriate Preventive Medicine Services “New Patient” or “Established Patient”
Current Procedural Terminology (CPT) code based on the age of the enrollee when submitting claims for
the services.
The information gathered during the preventive medicine visit is to be forwarded to any requesting
provider in order to communicate findings and prevent duplicative services.
Preventive medicine E&M services are comprehensive in nature and should reflect age and gender specific
services.
The medical record documentation must include, but is not limited to:
o Physical examination;
o Medical and social history review;
o Counseling/anticipatory guidance/risk factor reduction intervention; and
o Screening test(s) and results.
In addition, the MCO shall cover one preventive gynecological examination per calendar year for enrollees aged
21 and over when performed by a primary care provider or gynecologist. This is to allow enrollees to receive both
the necessary primary care and gynecological components of their annual preventive screening visits. The visit
must include:
Examination;
Sexually Transmitted Infection (STI) screening and counseling;
Breast and pelvic examination;
Pap smear, if appropriate; and
Contraceptive methods and counseling, as age appropriate.
If an abnormality or pre-existing problem is encountered and treatment is significant enough to require additional
work to perform the key components of a problem oriented E&M service on the same date of service by the
provider performing the preventive medicine service visit, the MCO shall not cover any additional office visit of a
higher level than CPT code 99212.
The MCO shall not require a referral for access to a women’s health specialist for routine and preventive women’s
health care services.
Radiology Services
The MCO shall cover inpatient and outpatient radiology services.
The MCO shall cover radiological services that may be required to treat an emergency or to provide surgical
services for an excluded service, such as dental services.
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The MCO shall not reimburse providers for the full service of radiology services that are not performed in the
providers’ own offices, including tests which are sent to other facilities for processing.
NOTE: Refer to the Laboratory Services and Portable X-Ray Services sections of this Manual for additional information.
ROUTINE CARE PROVIDED TO ENROLLEES PARTICIPATING IN
CLINICAL TRIALS
The MCO shall cover any item or service provided to an enrollee participating in a qualifying clinical trial to the
extent that the item or service would otherwise be covered for the enrollee when not participating in the
qualifying clinical trial. This includes any item or service provided to prevent, diagnose, monitor, or treat
complications resulting from participation.
Qualifying Clinical Trial
A qualifying clinical trial is defined as a clinical trial in any clinical phase of development that is conducted in
relation to the prevention, detection, or treatment of any serious or life-threatening disease or condition that
meets any of the following criteria:
The study or investigation is approved, conducted, or supported (which may include funding) by one or
more of the following:
o The National Institutes of Health.
o The Centers for Disease Control and Prevention.
o The Agency for Healthcare Research and Quality.
o The Centers for Medicare & Medicaid Services.
o A cooperative group or center of any of the entities described in subclauses (I) through (IV) or the
Department of Defense or the Department of Veterans Affairs.
o A qualified non-governmental research entity identified in the guidelines issued by the National
Institutes of Health for center support grants.
o The study or investigation is approved or funded by one or more of the following and has been
reviewed and approved through a system of peer review comparable to the system of peer review
of studies and investigations used by the National Institutes of Health which assures unbiased
review of the highest scientific standards by qualified individuals with no interest in the outcome
of the review:
The Department of Veterans Affairs
The Department of Defense.
The Department of Energy.
The clinical trial is conducted pursuant to an investigational new drug exemption under section 335(i) of
Title 21 or an exemption for a biological product undergoing investigation under section 262(a)(3) of this
title.
The clinical trial is a drug trial that is exempt from having such an investigational new drug application.
Coverage determinations shall be:
Expedited and completed within 72 hours;
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Made without limitation on the geographic location or network affiliation of the health care provider
treating such individual or the principal investigator of the qualifying clinical trial;
Based on attestation regarding the appropriateness of the qualifying clinical trial by the health care
provider and principal investigator using the following form and kept on file by the provider:
https://www.medicaid.gov/resources-for-states/downloads/medicaid-attest-form.docx
; and
Completed without any requirement of submission of the protocols of the qualifying clinical trial, or any
other documentation that may be proprietary or determined by the HHS Secretary to be burdensome to
provide.
Coverage Limitations
The MCO shall not cover any of the following:
The investigational item or service that is the subject of the qualifying clinical trial;
Any service provided to the individual solely to satisfy data collection and analysis needs for the qualifying
clinical trial and is not used in the direct clinical management of the individual; and
Services not otherwise covered by the MCO.
Sinus Procedures
Balloon ostial dilation and functional endoscopic sinus surgery are considered medically necessary for the
treatment of chronic rhinosinusitis when all of the following criteria are met:
Uncomplicated chronic rhinosinusitis limited to the paranasal sinuses without the involvement of adjacent
neurological, soft tissue, or bony structures that has persisted for at least 12 weeks with at least two of
the following sinonasal symptoms:
o Facial pain/pressure;
o Hyposmia/anosmia;
o Nasal obstruction;
o Mucopurulent nasal discharge; and
Sinonasal symptoms that are persistent after maximal medical therapy has been attempted, as defined
by all of the following, either sequentially or overlapping:
o Saline nasal irrigation for at least six weeks;
o Nasal corticosteroids for at least six weeks;
o Approved biologics, if applicable, for at least six weeks;
o A complete course of antibiotic therapy when an acute bacterial infection is suspected;
o Treatment of concomitant allergic rhinitis, if present; and
Objective evidence of sinonasal inflammation as determined by one of the following:
o Nasal endoscopy; or
o Computed tomography.
Balloon ostial dilation and functional endoscopic sinus surgery are not covered and not considered medically
necessary in the following situations:
Presence of sinonasal symptoms but no objective evidence of sinonasal disease by nasal endoscopy or
computed tomography;
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For the treatment of obstructive sleep apnea and/or snoring when the above criteria are not met;
For the treatment of headaches when the above criteria are not met; and
For balloon ostial dilation only, when sinonasal polyps are present.
Skin Substitutes for Chronic Diabetic Lower Extremity Ulcers
The MCO shall cover skin substitutes and consider them to be medically necessary for the treatment of partial-
and full-thickness diabetic lower extremity ulcers when the enrollee meets the criteria listed below.
Eligibility Criteria
The enrollee must meet all of the following criteria to be considered eligible:
Presence of a lower extremity ulcer that:
o Is at least 1.0 square centimeter (cm) in size;
o Has persisted for at least four weeks;
o Has not demonstrated measurable signs of healing, defined as a decrease in surface area and
depth or a decreased amount of exudate and necrotic tissue, with comprehensive therapy
including all of the following:
Application of dressings to maintain a moist wound environment;
Debridement of necrotic tissue, if present; and
Offloading of weight.
A diagnosis of type 1 or type 2 diabetes mellitus;
A glycated hemoglobin (HbA1c) level of ≤9% within the last 90 days or a documented plan to improve
HbA1c to 9% or below as soon as possible;
Evidence of adequate circulation to the affected extremity, as indicated by one or more of the following:
o Ankle-brachial index (ABI) of at least 0.7;
o Toe-brachial index (TBI) of at least 0.5;
o Dorsum transcutaneous oxygen test (TcPO2) >=30 mm Hg; and/or
o Triphasic or biphasic Doppler arterial waveforms at the ankle of the affected leg.
No evidence of untreated wound infection or underlying bone infection; and
Ulcer does not extend to tendon, muscle, joint capsule, or bone or exhibit exposed sinus tracts unless the
product indication for use allows application to such ulcers.
The enrollee must not have any of the following:
Active Charcot deformity or major structural abnormalities of the foot, when the ulcer is on the foot;
Active and untreated autoimmune connective tissue disease;
Known or suspected malignancy of the ulcer;
Enrollee is receiving radiation therapy or chemotherapy; and
Re-treatment of the same ulcer within one year.
Coverage Limitations
The following coverage limitations apply:
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Coverage is limited to a maximum of 10 treatments within a 12-week period;
If there is no measurable decrease in surface area or depth after five applications, then further
applications are not covered;
For all ulcers, a comprehensive treatment plan must be documented, including at least all of the following:
o Offloading of weight;
o Smoking cessation counseling and/or medications, if applicable;
o Edema control;
o Improvement in diabetes control and nutritional status; and
o Identification and treatment of other comorbidities that may affect wound healing such as
ongoing monitoring for infection.
While providers may change products used for the diabetic lower extremity ulcers, simultaneous use of
more than one product for the diabetic lower extremity ulcers is not covered; and
Hyperbaric oxygen therapy is not covered when used at the same time as skin substitute treatment.
Prior Authorization
The MCO shall require prior authorization, and medical documentation submitted must demonstrate that the
enrollee meets all of the aforementioned requirements. If there is no measurable decrease in surface area, or
depth, after five applications, then the MCO shall not cover further applications, even when prior authorized.
Sterilizations
Coverage Requirements
In accordance with federal regulations, the MCO shall cover sterilizations if the following requirements are met:
The individual is at least 21 years of age at the time the consent is obtained;
The individual is not a mentally incompetent individual;
The individual has voluntarily given informed consent in accordance with all federal requirements; and
At least 30 days, but no more than 180 days, have passed between the date of the informed consent and
the date of sterilization, except in the case of premature delivery or emergency abdominal surgery. An
individual may consent to be sterilized at the time of a premature delivery or emergency abdominal
surgery, if at least 72 hours have passed since an enrollee gave informed consent for the sterilization. In
the case of premature delivery, the informed consent must have been given at least 30 days before the
expected date of delivery.
The MCO shall not cover hysterectomies performed solely for the purpose of terminating reproductive capability
(sterilization). Refer to the Hysterectomies section of this Manual for additional information.
Sterilization Consent Form Requirements
The MCO shall direct providers to use the current sterilization consent forms (HHS-687 available in English and
HHS-687-1 available in Spanish) from the U.S. Department of Health and Human Services website [link
].
The MCO shall require the consent form to be signed and dated by:
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The individual to be sterilized;
The interpreter, if one was provided;
The person who obtained the consent; and
The physician performing the sterilization procedure.
NOTE: If the physician who performed the sterilization procedure is the one who obtained the consent, the physician must
sign both statements.
The physician who obtains the consent must share the consent form with all providers involved in that enrollee’s
care (e.g., attending physician, hospital, anesthesiologist, and assistant surgeon).
Enrollees who undergo a covered hysterectomy must complete a hysterectomy consent form but are not required
to complete a sterilization consent form. Refer to the Hysterectomies section of this Manual for additional
information.
Consent Forms and Name Changes
For services requiring a sterilization consent form, the enrollee’s name on the Medicaid file for the date of service
must be the same as the name signed at the time of consent. If the enrollee’s name is different, the provider must
attach a letter from the provider’s office from which the consent was obtained. The letter must be signed by the
physician and must state the enrollee’s name has changed and must include the enrollee’s social security number
and date of birth.
It is the MCO’s responsibility to ensure that required documentation is maintained by the provider.
Correcting the Sterilization Consent Form
The informed consent must be obtained and documented prior to the performance of the sterilization.
Errors in the following sections can be corrected, but only by the person over whose signature they appear:
“Consent to Sterilization”;
“Interpreter’s Statement”;
“Statement of Person Obtaining Consent”; and
“Physician’s Statement”.
If either the enrollee, the interpreter, or the person obtaining consent returns to the office to make a correction
to his or her portion of the consent form, the medical record must reflect his or her presence in the office on the
day of the correction.
To make an allowable correction to the form, the individual making the correction must line through the mistake
once, write the corrected information above or to the side of the mistake, and initial and date the correction.
Erasures, “write-overs”, or use of correction fluid in making corrections are unacceptable.
Only the enrollee can correct the date to the right of their signature. The same applies to the interpreter, to the
person obtaining consent, and to the doctor. The corrections of the enrollee, the interpreter, and the person
obtaining consent must be made before the claim is submitted.
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The date of the sterilization may be corrected either before or after submission by the doctor over whose
signature it appears. However, the operative report must support the corrected date.
Reimbursement
Prior to reimbursement, the MCO shall ensure that the sterilization consent form is obtained. The MCO shall allow
ancillary providers and hospitals to submit claims without the hard copy consent. The MCO shall reimburse these
providers only if the provider performing the sterilization submitted a valid sterilization consent and was
reimbursed for the procedure.
The MCO is responsible for maintaining required documentation and shall not shred documentation without prior
approval by LDH.
Substitute Physician Billing
The MCO shall allow both the reciprocal billing arrangement and the locum tenens arrangement when providers
utilize substitute physician services.
Reciprocal Billing Arrangement
A reciprocal billing arrangement occurs when a regular physician or group has a substitute physician provide
covered services to a Medicaid enrollee on an occasional reciprocal basis. A physician can have reciprocal
arrangements with more than one physician. The arrangements need not be in writing.
The enrollee’s regular physician may submit the claim and receive reimbursement for covered services which the
regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if:
The regular physician is unavailable to provide the services.
The substitute physician does not provide the services to Medicaid enrollees over a continuous period of
longer than 60 days.
NOTE: A continuous period of covered services begins with the first day on which the substitute physician provides covered
services to Medicaid enrollees of the regular physician, and ends with the last day on which the substitute physician provides
these services to the enrollees before the regular physician returns to work. This period continues without interruption on
days on which no covered services are provided on behalf of the regular physician. A new period of covered services can
begin after the regular physician has returned to work. If the regular physician does not come back after the 60 days, the
substitute physician must bill for the services under his or her own Medicaid provider number.
The regular physician identifies the services as substitute physician services by entering the Healthcare
Common Procedure Coding System (HCPCS) modifier - Q5 after the procedure code on the claim. By
entering the -Q5 modifier, the regular physician (or billing group) is certifying that the services billed are
covered services furnished by the substitute physician for which the regular physician is entitled to submit
Medicaid claims.
The regular physician must keep on file a record of each service provided by the substitute physician and
make the record available to Louisiana Medicaid or its representatives upon request.
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This situation does not apply to the substitution arrangements among physicians in the same medical group where
claims are submitted in the name of the group. On claims submitted by the group, the group physician who
actually performed the service must be identified.
Locum Tenens Arrangement
A locum tenens arrangement occurs when a substitute physician is retained to take over a regular physician’s
professional practice for reasons such as illness, pregnancy, vacation, or continuing medical education. The
substitute physician generally has no practice of his or her own. The regular physician usually pays the substitute
physician a fixed amount per diem, with the substitute physician being an independent contractor rather than an
employee.
The regular physician can submit a claim and receive reimbursement for covered services of a locum tenens
physician who is not an employee of the regular physician if:
The regular physician is unavailable to provide the services.
The regular physician pays the locum tenens for his or her services on a per diem or similar fee-for-time
basis.
The substitute physician does not provide the services to Medicaid enrollees over a continuous period of
longer than 60 days.
NOTE: A continuous period of covered services begins with the first day on which the substitute physician provides covered
services to Medicaid enrollees of the regular physician, and ends with the last day on which the substitute physician provides
these services to the enrollees before the regular physician returns to work. This period continues without interruption on
days on which no covered services are provided on behalf of the regular physician. A new period of covered services can
begin after the regular physician has returned to work. If the regular physician does not come back after the 60 days, a new
60-day period can begin with a different locum tenens doctor.
The regular physician identifies the services as substitute physician services by entering HCPCS modifier -
Q6 after the procedure code on the claim.
The regular physician must keep on file a record of each service provided by the substitute physician and
make the record available to Louisiana Medicaid, contracted MCOs, or its representatives upon request.
Telemedicine/Telehealth
Telemedicine/telehealth is the use of a telecommunications system to render healthcare services when a
physician or other licensed practitioner and an enrollee are not in the same location.
The telecommunications system shall include, at a minimum, audio and video equipment permitting two-way,
real-time interactive communication between the beneficiary at the originating site and the physician or other
licensed practitioner at the distant site. The telecommunications system must be secure, ensure patient
confidentiality, and be compliant with the requirements of the Health Insurance Portability and Accountability
Act.
Originating site means the location of the Medicaid enrollee at the time the services are provided. There is no
restriction on the originating site and it can include, but is not limited to, a healthcare facility, school, or the
enrollee’s home.
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Distant site means the site at which the physician or other licensed practitioner is located at the time the services
are provided. When approved by LDH in accordance with the Contract, the distant site may include a provider or
facility that is not physically located in this state in temporary or emergency situations (e.g., pandemics, natural
disasters).
When otherwise covered, the MCO shall cover services located in the Telemedicine appendix of the CPT manual,
or its successor, when provided by telemedicine/telehealth. In addition, the MCO shall cover other services
provided by telemedicine/telehealth when indicated as covered via telemedicine/telehealth in Medicaid program
policy. The MCO shall ensure adequate availability of telemedicine/telehealth during declared emergencies,
disasters, and pandemics. Physicians and other licensed practitioners must continue to adhere to all existing
clinical policy for all services rendered. Providing services through telemedicine/telehealth does not remove or
add any medical necessity requirements.
Reimbursement
The MCO shall reimburse the distant site provider for services provided via telemedicine/telehealth.
Reimbursement for services provided by telemedicine/telehealth is at the same level as services provided in
person.
The MCO shall require the provider to include in the enrollee’s clinical record documentation that the service was
provided through the use of telemedicine/telehealth.
The distant site provider must be enrolled as a Louisiana Medicaid provider to receive reimbursement for covered
services rendered to Louisiana Medicaid enrollees.
Billing
Medicaid covered services provided using telemedicine must be identified on the claims submissions form by
appending the modifier “95” to the applicable procedure code and indicating Place of Service (POS) 02 (other than
home) or 10 (home). The MCO shall deny claims that do not have both the correct POS and modifier present on
the claim.
Therapy Services
The MCO shall cover speech therapy, physical therapy, and occupational therapy services to enrollees of any age
and without restrictions to place of service.
Tobacco Cessation Counseling Services
The MCO shall cover tobacco cessation counseling services for enrollees who use tobacco products or who are
being treated for tobacco use when provided by, or under the supervision of, the enrollee’s primary care provider
or other appropriate healthcare professionals.
The MCO shall cover up to four tobacco cessation counseling sessions per quit attempt, up to two quit attempts
per calendar year, for a maximum of eight counseling sessions per calendar year. These limits may be exceeded if
deemed medically necessary.
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Provider Qualifications
The entity rendering tobacco cessation counseling services must be an enrolled Medicaid provider.
Health care professionals who may provide tobacco cessation counseling include physicians, advanced practice
registered nurses, and physicians’ assistants, as well as mental health providers who are licensed to practice
independently. Other professional or paraprofessional healthcare practitioners must have completed training in
the provision of tobacco cessation counseling and must provide services under the supervision of a licensed
practitioner.
Reimbursement
Minimum reimbursement for tobacco cessation counseling shall be based on the applicable current procedural
terminology (CPT) code on the Professional Services Fee Schedule and must be supported by appropriate
documentation.
Vagus Nerve Stimulators
The MCO shall cover implantation of the vagus nerve stimulator (VNS) when the treatment is considered medically
necessary, the enrollee meets the published criteria, and the enrollee has a diagnosis of medically intractable
epilepsy.
Criteria for Enrollee Selection
The following criteria shall be used to determine medical necessity of the VNS:
Partial epilepsy confirmed and classified according to the International League Against Epilepsy (ILAE)
classification. The enrollee may also have associated generalized seizures, such as tonic, tonic-clonic, or
atonic. The VNS may have efficacy in primary generalized epilepsy as well;
Age 12 years or older, although case by case consideration may be given to younger children who meet
all other criteria and have sufficient body mass to support the implanted system;
Seizures refractory to medical anti-epilepsy treatment, with adequately documented trials of appropriate
standard and newer anti-epilepsy drugs or documentation of enrollee’s inability to tolerate these
medications;
Enrollee has undergone surgical evaluation and is considered not to be an optimal candidate for epilepsy
surgery;
Enrollee is experiencing at least four to six identifiable partial onset seizures each month. Enrollee must
have had a diagnosis of intractable epilepsy for at least two years. The two-year period may be waived if
waiting would be seriously harmful to the enrollee to six identifiable partial onset seizures each month.
Enrollee must have had a diagnosis of intractable epilepsy for at least two years. The two-year period may
be waived if waiting would be seriously harmful to the enrollee;
Enrollee must have undergone quality of life (QOL) measurements. The choice of instruments used for
the QOL measurements must assess quantifiable measures of daily life in addition to the occurrence of
seizures; and
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In the expert opinion of the treating physician, there must be reason to believe that QOL will improve as
a result of implantation of the VNS. This improvement should occur in addition to the benefit of seizure
frequency reduction. The treating physician must document this opinion clearly.
Exclusion Criteria
Regardless of the criteria for enrollee selection, the MCO shall not cover VNS implantation if the enrollee has one
or more of the following criteria:
Psychogenic seizures or other non-epileptic seizures;
Insufficient body mass to support the implanted system;
Systemic or localized infections that could infect the implanted system; or
A progressive disorder contraindicated to VNS implantation (e.g., malignant brain neoplasm, Rasmussen’s
encephalitis, Landau-Kleffner syndrome and progressive metabolic and degenerative disorders).
Place of Service Restriction
The MCO shall restrict coverage of the surgery to implant the VNS to an outpatient hospital, unless medically
contraindicated.
Coverage Requirements
Coverage for vagus nerve stimulation shall include, but is not limited to, the following:
Vagus nerve stimulator;
Implantation of VNS;
Programming of the VNS; and
Battery replacement.
IN LIEU OF SERVICES
“In lieu of” services (ILOS) are alternative services or settings covered by the MCO as a substitute or alternative
to services or settings covered under the Louisiana Medicaid State Plan. In accordance with 42 C.F.R. § 438.3(e)(2),
ILOS are medically appropriate and cost-effective substitute services that are offered voluntarily by the MCO. If
offered, the MCO may not require enrollees to use any ILOS and the MCO reserves the right to cap or limit the
number of enrollees receiving the ILOS at any time and for any reason. This section lists all approved ILOS that
may be offered by the MCO.
Physical Health Services
MCOs must notify LDH of their intent to offer any of the authorized ILOS within this section and provide their
policies for prior approval. Authorized physical health ILOS include the following:
Chiropractic services for adults age 21 and older
Doula services
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Hospital-based care coordination for pregnant and postpartum individuals with substance use disorder
and their newborns
Outpatient lactation support
Remote patient monitoring
Chiropractic Services for Adults Age 21 and Older
The purpose of this ILOS is to provide coverage of chiropractic care for enrollees age 21 and older. Chiropractic
services to diagnose and treat neuromusculoskeletal conditions associated with the functional integrity of the
spine are a medically appropriate and cost-effective substitute for services currently covered under the Louisiana
Medicaid State Plan.
Provider Qualification
Qualified providers must be enrolled in Medicaid and meet the following requirements:
Current, valid, and unrestricted Louisiana chiropractic license
Nothing herein shall be construed to require the MCO to execute an agreement with any qualified and willing
provider. The MCO reserves the right to execute agreements with qualified providers only as needed to
successfully provide services, if the MCO elects to offer this ILOS.
Covered Services
As part of this ILOS, chiropractic services for the purpose of diagnosing and treating neuromusculoskeletal
conditions associated with the functional integrity of the spine are covered and considered medically necessary.
The following requirements apply.
Evaluation and Management Services
The initial visit must include a treatment plan, including:
Level of care (duration and frequency of visits);
Treatment goals; and
Measures to assess the effectiveness of treatment (qualitative and/or quantitative).
Follow-up visits must include information on the enrollee’s progress in the treatment plan, along with the
measures used to assess effectiveness.
The level of evaluation and management service shall be determined by using Current Procedural Terminology
(CPT) guidelines.
X-Rays
X-rays may be used to assess the enrollee’s condition. X-rays must be limited to the level(s) of suspected
abnormality and the minimum number of views necessary to establish the diagnosis. Repeat X-rays are not
considered medically necessary in the absence of a significant worsening of symptoms despite treatment, a
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change in the pattern of symptoms which may suggest an alternate diagnosis, or the development of new
symptoms.
Spinal Manipulation
Spinal manipulation of up to five regions is covered and considered medically necessary when included in the
documented treatment plan.
Other Treatments
Other treatments refer to chiropractic treatments other than spinal manipulation. On each date of service, a
maximum of two other treatments are covered and must be tailored to the enrollee’s condition and identified in
the documented treatment plan.
Mechanical traction
Whirlpool therapy
Ultrasound therapy
Electrical stimulation
Therapeutic exercises
Neuromuscular reeducation
Gait training
Massage therapy
Manual therapy
Dry needling
Prior Authorization and Referral
Chiropractic ILOS are covered without the requirement of prior authorization for up to 18 treatment sessions
annually. Additional treatment sessions may be reimbursed with authorization by the MCO. A treatment session
is defined as all chiropractic services that occur on a single date of service. A referral from a primary care provider
or any other provider is not required.
Reimbursement
Reimbursement for chiropractic services is only available to qualifying providers, as determined by the MCO.
Non-Compliance, Recoupment, and Sanctions
Use of all procedure codes must be in accordance with CPT guidance. Non-compliance with CPT guidance, failure
to maintain adequate medical documentation to substantiate services rendered, or non-compliance with any of
the provisions described in this document may result in recoupment and/or other sanctions as determined by the
MCO.
Procedure Codes
The below table represents the procedure codes covered under this ILOS. The fees listed are calculated according
to the methodology that would be employed by Medicaid FFS; however, the MCO has the discretion to execute
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agreements with providers for a different rate, when mutually agreeable. As specified above, a maximum of two
other treatments, in addition to spinal manipulation, may be reimbursed per date of service.
Service
Category
Code
Description
Reference
Fee
Evaluation and
management –
new patient
99202
Office or other outpatient visit for the evaluation and management
of a new patient
$42.77*
99203
$62.18*
99204
$96.56*
99205
$122.19*
Evaluation and
management –
established
patient
99212
Office or other outpatient visit for the evaluation and management
of an established patient
$24.83*
99213
$41.53*
99214
$62.65*
99215
$84.93*
Spinal X-rays
72020
Radiologic examination, spine, single view, specify level
$15.31*
72040
Radiologic examination, spine, cervical; 2 or 3 views
$23.32*
72050
Radiologic examination, spine, cervical; 4 or 5 views
$33.27*
72052
Radiologic examination, spine, cervical; 6 or more views
$41.69*
72070
Radiologic examination, spine, thoracic, 2 views
$22.60*
72072
Radiologic examination, spine, thoracic, 3 views
$24.99*
72074
Radiologic examination, spine, thoracic, minimum of 4 views
$29.46*
72080
Radiologic examination, spine, thoracolumbar, 2 views
$23.29*
72100
Radiologic examination, spine, lumbosacral; 2 or 3 views
$24.49*
72110
Radiologic examination, spine, lumbosacral; minimum of 4 views
$34.22*
72114
Radiologic examination, spine, lumbosacral; complete, including
bending views, minimum of 6 views.
$44.25*
72120
Radiologic examination, spine, lumbosacral; bending views only, 2
or 3 views
$30.63*
72220
Radiologic examination, sacrum and coccyx, minimum of 2 views
$19.65*
Spinal
manipulation
98940
Spinal Manipulation 1-2 Regions
$16.87*
98941
Spinal Manipulation 3-4 Regions
$23.40*
98942
Spinal Manipulation 5 Regions
$38.13†
Other
treatments‡
97012
Mechanical Traction
$10.76†
97014
Electrical Stimulation (unattended)
$8.86†
97022
Whirlpool Therapy
$12.55†
97035
Ultrasound Therapy
$10.40†
97032
Electrical Stimulation (attended)
$11.01*
97110
Therapeutic Exercises
$19.15*
97112
Neuromuscular Reeducation
$19.59*
97116
Gait Training
$16.72*
97124
Massage Therapy
$15.20*
97140
Manual Therapy
$17.72*
20560
Needle insertion without injection 1-2
$19.10†
20561
Needle insertion without injection 3 or more muscles
$27.39†
*From the Medicaid FFS fee schedule, as applicable to adults age 21 and older.
†Reference fee calculated using the methodology that would be employed by Medicaid FFS.
‡A maximum of two (2) other treatments, in addition to spinal manipulation, are covered per day of service.
MCO Manual | SERVICES | In Lieu of Services 184
Note: These fees are provided for reference purposes only, and the MCO may establish different fees in its
agreements with providers.
Hospital-Based Care Coordination for Pregnant and Postpartum
Individuals with Substance Use Disorder and Their Newborns
The purpose of this ILOS is to provide coverage of a comprehensive pregnancy medical home model of care to
enrollees with substance use disorder (SUD) who are 18 years of age and older and pregnant or up to 12 months
postpartum. The model includes care coordination, health promotion, individual and family support, and linkages
to community/support services, behavioral, and physical health services. The model does not include coverage of
physical and behavioral health services otherwise covered under the Louisiana Medicaid State Plan (e.g.,
outpatient OB care, SUD treatment services). In addition, this ILOS is not duplicative of MCO case management
services.
This ILOS is a medically appropriate substitute for acute care utilization (e.g., emergency department visits,
inpatient hospitalizations) due to inadequately-treated SUD during the pregnancy and postpartum periods. The
benefit will not serve as a substitute for medically necessary physical and behavioral health services such as
obstetrical care or SUD care. Rather, the ILOS will help to ensure that enrollees receive comprehensive physical
and behavioral health care services that meet their needs, while avoiding preventable use of acute care.
Provider Qualifications
Eligible and qualified providers are hospitals that are enrolled in Medicaid and provide outpatient services with
the following staffing specifications:
At least one licensed mental health professional (LMHP), such as an LCSW or LPC with a current, valid, and
unrestricted Louisiana license;
Additional staff may include LMHPs, registered nurses, or advanced practice registered nurses with a
current, valid, and unrestricted Louisiana license; and
A staffing ratio of at least one LMHP or nurse for every 40 enrollees must be maintained.
Nothing herein shall be construed to require the MCO to execute an agreement with any qualified and willing
provider. The MCO reserves the right to execute agreements with qualified providers only as needed to
successfully provide services, if the MCO elects to offer this ILOS.
Covered Services
Services covered under the model are divided into three categories:
Intake, assessment, and care plan development;
Care coordination; and
Outreach for disengaged enrollees.
Description
Services Provided
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Intake, Assessment,
Care Plan
Development
Time requirement:
2.5 hours total time
(face-to-face and
non-face-to-face
time)
Intake:
• Pregnancy confirmation; referral to OB if needed
• Explanation of services
• Obtaining informed consent for treatment
• Obtaining detailed medical and social history
• Create a mapping tool of contacts
Needs assessment through screenings:
• Initiate assessment of unmet care needs for physical (medical and nutritional),
behavioral and psychosocial needs. At a minimum, these assessments are
completed:
o 5 P’s Screening tool
o DSM-5 Opioid Use Disorder Screening
o NIDA Substance Use Screen
o PHQ9 Depression Screening
o GAD-7 Generalized Anxiety Disorder Screening
o SDOH Health Leads Screening
Additional screenings may be added, to include:
o Columbia Suicide Severity Rating Scale
o Perinatal Posttraumatic Stress Disorder Questionnaire
o PCL-C PTSD Checklist – Civilian version
o ACE Adverse Childhood Experience Questionnaire
o MDQ Mood Disorder Questionnaire
o HITS Intimate Partner Violence Screening
Plan of care development:
• Review assessments to identify care needs and discussing results with patient
• Develop treatment plan of patient-centered goals, including referral to
medication-assisted treatment (MAT) or SUD treatment
• Assessing urgency of identified goals, prioritizing referrals based on needs,
including housing referrals
• Obtain plan of care developed by MCO case management, if applicable, for
incorporation
• Assessing Care Plan understanding through teach back to uncover any
misunderstanding of the plan, the medical condition and objections. Adjusting
plan and referrals as needed.
• Providing warm handoff to referral sources.
• Notification to MCO case managers of enrollment
All activities shall be documented fully.
Care Coordination
Time requirement: 10
hours per month of
total time (face-to-
face and non-face-to-
PRENATAL
General Activities
• Confirmation of consent
• Confirm and update birth plans
•
Confirm and update contact information
MCO Manual | SERVICES | In Lieu of Services 186
face time). Non-face-
to-face-time can
include, but is not
limited to:
• Warm handoffs
to other
providers and
community
services
• Contacting and
communicating
with physical and
behavioral health
providers
• Following up on
outcomes of
referrals or visits
• Updating the
enrollee’s care
plan
• Assisting with benefit reinstatement, if indicated
Care Coordination
• Coordination of referrals identified from treatment plan, incorporating
collaboration with the MCOs as needed to improve effectiveness and prevent
duplication
• Review and revision of care plan, as needed
• Visit preparation, navigation, and follow up for key OB services
• Coordination with MCO Case Manager to enhance care and prevent duplication
• Multidisciplinary long-term postpartum follow-up includes referrals for medical,
developmental, and social support for mother and infant
Risk Assessment
• Reviewing patient history from referral source (if applicable) and medical charts
• Reassess physical, mental and social needs; identifying gaps
• Providing assistance to close gaps for physical, mental and social needs
• Review risks identified during assessment and addressing those risks
• Assisting with development of peer support
Alcohol/Substance Use Disorder Treatment
• Interdisciplinary case conference with hospital care team during pregnancy,
delivery and postpartum periods, including patient care plan.
• Participation at SUD Treatment Case Conference, if indicated
• Providing referral and/or education for Naloxone
Health Education and Promotion
• Orientation to labor and delivery process, including pain management plan and
discussion of post-partum family planning, education on the importance of post-
partum care
• Provide individualized education on pregnancy, childbirth, parenting, physical
well-being, lactation support and information on Neonatal Abstinence Support
and related topics
DELIVERY CARE
• In-hospital, rooming in and assessment of neonatal opioid withdrawal syndrome
(NOWS), if required staffing and space are available
• Lactation support and follow up education
• Assessing baby safety needs
• Navigating and educating mother for potential NICU admission, as needed
• Assessment of care transition to home
POSTPARTUM CARE
Care Coordination
• Identifying/connecting patient with peer support
• Provide referrals for medical, developmental and social support, (WIC, Healthy
Start, Early Steps)
MCO Manual | SERVICES | In Lieu of Services 187
• Follow meconium drug screening and report to DCFS, if appropriate
• Visit preparation and follow up for pediatric visits
• Assist with/make referral to pediatrician
• Identifying NOWS and neonatal abstinence syndrome (NAS) support by care
partners
Health Education and Promotion
• Discussion of postpartum needs, including importance of postpartum care, red
flag warnings for postpartum hygiene, signs and symptoms of illness for mother,
sleep and nutritional needs.
• Discussion of red flag warnings for signs and symptoms of newborn illness,
feeding and lactation support, care of baby’s skin, mouth, umbilical cord and
circumcision
Risk Assessment
• Reassessment for depression and anxiety screening with on-site treatment or
referral as indicated
• Provide education and advocacy for DCFS reporting and the justice system
• Documentation of activities and progress across all categories of care
coordination activities
Outreach for
Disengaged Enrollees
Time requirement: 8
hours per month total
time (face-to-face
and non-face-to-face
time).
• Maintaining and reviewing call log for potential disengagement
• Medical record review for missed physician or diagnostic appointments
• Checking with SUD treatment providers for missed appointments
• Contact attempts by preferred contact method at least three times on different
days and different times of day
• Escalating contact tracking to friends, family, employer, judicial, social services,
etc., from contact mapping
• Documentation of efforts made for outreach attempts
Prior Authorization and Referral
Services under this ILOS are covered without the requirement of prior authorization or referral. The MCO may
make referrals to providers of this service at its discretion.
Reimbursement
Reimbursement for these services is only available to qualifying providers, as determined by the MCO. Providers
are advised to contact the MCOs for specific additional guidance prior to rendering services.
Non-Compliance, Recoupment, and Sanctions
Use of all procedure codes must be in accordance with this terms and conditions described in this document.
Failure to maintain adequate medical documentation to substantiate services rendered or non-compliance with
any of the provisions described in this document may result in recoupment and/or other sanctions as determined
by the MCO.
MCO Manual | SERVICES | In Lieu of Services 188
Procedure Codes
The below table represents the procedure codes covered under this ILOS. The fees listed are estimated by
Medicaid’s actuarial consultant based on a time study; however, the MCO has the discretion to execute
agreements with provider for a different rate, when mutually agreeable.
Service
Service
Code
Maximum Units
per Pregnancy
and Postpartum
Period
Estimated Fee
Intake, Assessment, Care Plan Development
H0002
1
$77.60/unit
Care Coordination
H0006
20
$221.06/unit
(1 unit = 1 month)
Outreach for Disengaged Enrollees
H0023
4
$133.63/unit
(1 unit = 1 month)
The primary diagnosis code on the claim should reflect the primary substance use disorder experienced by the
enrollee.
Outpatient Lactation Support
The purpose of this ILOS is to provide coverage of outpatient lactation support services for enrollees who are
breastfeeding or exclusively pumping. Outpatient lactation support services for breastfeeding care and for the
diagnosis and treatment of breastfeeding issues are a medically appropriate and cost-effective substitute for
services currently covered under the Louisiana Medicaid State Plan, such as evaluation and treatment provided
by an obstetric or pediatric provider in the outpatient hospital or office setting. This ILOS is not duplicative of MCO
case management services or Doula ILOS.
Exclusive breastfeeding is recommended for the first six months of an infant’s life with continued breastfeeding
after solid foods are introduced for as long as is desired. There are numerous health benefits to breastfeeding, for
both the breastfeeding enrollee and their infant, which can reduce overall medical spending. Societal, medical,
and workplace challenges that often hinder breastfeeding may be mitigated with lactation support and
assessment in the outpatient setting. Interventions to support breastfeeding have been found to increase
breastfeeding duration and are recommended by the U.S. Preventive Services Task Force.
Provider Qualification
Qualified lactation support providers must have achieved and maintain certification as a Breastfeeding Counselor
or Lactation Consultant, as described by the United States Breastfeeding Committee [link
]. A Breastfeeding
Counselor is qualified to provide breastfeeding counseling, address normal breastfeeding in healthy term infants,
and to conduct maternal and infant assessments of anatomy, latch, and positioning, while providing support. A
Lactation Consultant is qualified to provide the same services as a Breastfeeding Counselor and is additionally
certified by the International Board of Lactation Consultant Examiners to address the full range of breastfeeding
care, particularly involving high acuity breastfeeding situations.
MCO Manual | SERVICES | In Lieu of Services 189
MCOs who enroll lactation support providers are responsible for verifying and maintaining documentation that
qualification criteria are met.
Nothing herein shall be construed to require the MCO to execute an agreement with any qualified and willing
lactation support provider. The MCO reserves the right to execute agreements with qualified lactation support
providers only as needed to successfully provide services, if the MCO elects to offer this ILOS.
Covered Services
As part of this ILOS, outpatient lactation support services for the purpose of providing breastfeeding care and for
the diagnosis and treatment of breastfeeding or pumping issues are covered and considered medically necessary
for any enrollee who is pregnant, breastfeeding, or expressing breastmilk for the purposes of providing nutrition
to an infant.
There is no restriction as to the site of service, which may include, but is not limited to, a healthcare facility, clinic
setting, community setting, or the enrollee’s home. Delivery of the service through a synchronous audio/video
telehealth modality is also permissible. Telehealth services must adhere to the Telemedicine/Telehealth section
of this Manual.
Prior Authorization and Referral
Lactation support provider ILOS are covered without the requirement of prior authorization for up to six total
treatment sessions that occur during pregnancy or while less than 24 months postpartum. Additional treatment
sessions may be reimbursed with authorization by the MCO. A treatment session is defined as all lactation support
services that occur on a single date of service. A referral from a primary care provider or any other provider is not
required.
Reimbursement
Reimbursement for lactation support services is only available to qualifying providers, as verified by the MCO.
A lactation support provider who provides services to more than one enrollee at a time must bill appropriately
using the approved code associated with lactation classes. This is limited to eight unique enrollees per session.
Non-Compliance, Recoupment, and Sanctions
Use of all procedure codes must be in accordance with CPT guidance. Non-compliance with CPT guidance, failure
to maintain adequate medical documentation to substantiate services rendered, or non-compliance with any of
the provisions described in this document may result in recoupment and/or other sanctions as determined by the
MCO.
Approved Procedure Codes
The below table represents the procedure codes covered under this ILOS. The MCO has the discretion to execute
agreements with providers for rates based on complexity and provider training.
MCO Manual | SERVICES | In Lieu of Services 190
Service Category
Procedure
Code
Modifier ICD-10 Description
Lactation Support
Provider Visit
S9445 33 Z39 .1
Patient education, non-physician provider,
individual session
Lactation Classes S9443 Z39.1
Lactation classes, non-physician provider;
group sessions must be at least 60 minutes
Provider Enrollment and MCO Registry Specifications
Qualified providers must possess a current certification as an International Board-Certified Lactation Consultant
(IBCLC), Advanced Lactation Consultant (ALC), Advanced Nurse Lactation Consultant (ANLC), Certified Lactation
Consultant (CLC), Certified Breast Feeding Specialist (CBS), or Certified Lactation Education (CLE) and enroll with a
valid NPI and taxonomy code(s) identified in the following chart.
MCO Manual | SERVICES | In Lieu of Services 191
Subspecialty Designations
Subspecialty
Subspecialty Description
CB
Certified Breastfeeding Specialist (CBS)
CL
Certified Lactation Counselor (CLC)
CE
Certified Lactation Educator (CLE)
AN
Advanced Nurse Lactation Consultant (ANLC)
IB
International Board Certified Lactation Consultant (IBCLC)
AL
Advanced Lactation Consultant (ALC)
Provider
Type
Provider Type
Description
Provider
Specialty
Provider Specialty
Description
Primary
Taxonomy
Primary Taxonomy
Description
Secondary
Taxonomy
Subspecialty
Entity
Type
DL
Doula
BC
Certified Breastfeeding
Consultant
374J00000X
Doula
174N0000X
CB, CL or CE
1
LS
Lactation
Support Provider
BC
Certified Breastfeeding
Consultant
174N00000X
Breastfeeding
Consultant
CB, CL or CE
1
LS
Lactation
Support Provider
LC
Certified Lactation
Consultant
163WL0100X
Registered Nurse
Lactation
Consultant
AN, IB, or AL
1
LS
Lactation
Support Provider
LC
Certified Lactation
Consultant
174N00000X
Lactation
Consultant, Non-
RN
IB or AL
1
MCO Manual | SERVICES | In Lieu of Services 192
Claims and Encounter Billing Requirements
Doula providers must meet outpatient lactation support policy requirements to receive reimbursement for
lactation support visits (S9445, modifier 33).
The rendering provider NPI is required when different from the billing provider.
The taxonomy code is required when adjudication is known to be impacted by the provider taxonomy.
Claims and encounters must be billed on the CMS1500/837P.
Outpatient lactation consultant services provided using telemedicine must be identified on claims and encounters
by appending the modifier “95” to the applicable procedure code and indicating place of service (POS) 02 or 10.
The MCO shall deny claims that do not have both the correct POS and modifier present on the claim.
Behavioral Health Services
MCOs must notify LDH of their intent to offer any of the authorized ILOS within this section and provide their
proposed service definitions for prior approval. Authorized behavioral health ILOS include the following:
23-Hour observation bed services for adults age 21 and older
Freestanding psychiatric hospitals for adults ages 21-64
Injection services provided by licensed nurses to adults age 21 and older
Mental Health Intensive Outpatient Programs
Population health management programs
Therapeutic Day Center for ages 5-20
Integrated Behavioral Health Homes
Visions of Hope Community Services
23-Hour Observation Bed Services for Adults Age 21 and Older
This ILOS is an inpatient hospital-based intervention designed to allow for the opportunity to hold and assess an
enrollee without admitting them.
Freestanding Psychiatric Hospitals for Adults Ages 21-64
The purpose of this ILOS is to assist adult enrollees with significant behavioral health challenges. This population
is often treated in more expensive general hospital psychiatric units, which creates access issues as beds in this
setting are limited. Individuals often remain in emergency departments while waiting for available beds, thereby
increasing costs to the healthcare system as they utilize those medical resources while awaiting beds in general
hospitals. Use of freestanding psychiatric units reduces emergency department consumption, increases
psychiatric bed capacity, and provides a less costly alternative to general hospital beds.
MCO Manual | SERVICES | In Lieu of Services 193
Injection Services Provided by Licensed Nurses to Adults Age 21 and
Older
Many enrollees are unable or unwilling to take oral psychotropics, or their mental status indicates a need for
injectable medication to ensure compliance and stability. Embedded in the cost of many E&M coded visits is the
cost of providing injectable medications. Allowing licensed nurses instead of physicians to perform this service
delivery results in the most cost efficient and least costly service delivery, and helps to ensure compliance. The
goals are reducing subsequent office visits and reducing hospitalizations due to lack of compliance.
Mental Health Intensive Outpatient Programs
Mental Health Intensive Outpatient Programs (MH IOPs) provide enrollees treatment via the least restrictive level
of care, allowing an alternative to inpatient hospitalization or Assertive Community Treatment and providing a
step-down option from inpatient hospitalization for enrollees at high risk for readmission.
Population Health Management Programs
Mindoula Clinical Services’ Population Health Management Program (PHMP) is a precision solution that targets,
engages, and serves enrollees with SMI, SUD, and/or Sickle Cell Disease (SCD) and other comorbid medical
conditions through team-based, tech-enabled, care extension services. This focused approach includes (1)
identification of enrollees for the PHMP using proprietary algorithms and enrollee archetype data, (2) outreach
and enrollment of enrollees using an intake process specific to SMI, SUD, and SCD populations, and (3) provision
of tech-enabled programmatic interventions that include content and methods tailored to reducing total costs of
care by addressing behavioral, medical, and social needs specific to SMI, SUD, and SCD populations.
These interventions are designed to enhance participants’ skills, strategies, and supports, which in turn help to
prevent and reduce unnecessary and avoidable medical costs associated with SMI, SUD, SCD, and other comorbid
medical conditions, during the program and even after its completion.
Therapeutic Day Center for Ages 5-20
The Center for Resilience is a therapeutic day center which provides educational and intensive mental health
supports in an innovative partnership with the Tulane University Medical School Department of Child and
Adolescent Psychiatry to ensure the emotional well-being and academic readiness of children with behavioral
health needs. Children receive instructional, medical, and therapeutic services at the day program site with the
goal of building the skills necessary to successfully transition back to the traditional school setting. Center for
Resilience provides a caring, non-punitive, therapeutic milieu with positive behavioral supports, trauma-informed
approaches, evidence-based mental health practices, small-group classroom instruction, and therapeutic
recreation activities. The leadership team is comprised of clinicians, educators, and medical doctors, and the
therapeutic milieu is a result of this intentionally interdisciplinary collaboration. The goal of this ILOS is to reduce
incidents of crisis hospitalization and residential psychiatric care.
MCO Manual | SERVICES | Value-Added Benefits 194
Integrated Behavioral Health Homes
Integrated Behavioral Health Homes (IBHH) is a value-based program that furthers alternative payment
methodologies and integration by improving medical, behavioral, and social healthcare outcomes for participants
while decreasing the overall total cost of care. MCOs who offer this ILOS will contract with qualified providers to
deliver the six core services that are central to Medicaid health homes, as outlined by the ACA and endorsed by
CMS, Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Council for Mental
Wellbeing:
Comprehensive care management;
Care coordination;
Health promotion;
Comprehensive transitional care and follow-up;
Patient and family support; and
Referrals to community and social support services.
The eligible population will be identified by the MCO and assigned to the participating providers within the eligible
population’s geographical area. This is an opt-in model and does not require enrollees to change or adjust any of
their existing provider relationships.
Visions of Hope Community Services
The Visions of Hope Community Services (VOH-CS) program is a comprehensive and intensive service bundling for
high-risk, low-functioning individuals with severe and persistent mental illness. This model addresses whole
person care that combines behavioral health while addressing social determinants of health and providing physical
health coordination and support. The VOH-CS program serves individuals who would have difficulty navigating
services across multiple, disconnected providers and thus are at greater risk of hospitalization, homelessness,
substance use, victimization and incarceration. This model offers daily socialization opportunities for this
population who might not interact socially with their peers in other settings.
VALUE-ADDED BENEFITS
The MCO shall identify value-added benefits (VAB) in encounter data in accordance with the MCO System
Companion Guide. The MCO shall also report VAB in financial data in accordance with the Financial Reporting
Guide.
Enrollee incentives may be offered as a form of VAB to promote healthy behavior. Examples of permissible
incentives include healthcare items or services (e.g., blood sugar screenings, cholesterol tests, medic alert jewelry)
and non-health care items or services (e.g., gift certificates, t-shirts, infant car seats). Cash or instruments
convertible to cash are not permissible.
The MCO may amend VAB subject to the requirements and timeframes specified in the Contract. When requesting
such revisions, the MCO should provide the following information for each VAB to LDH:
Type of request (e.g., new, removal, revision);
VAB name;
MCO Manual | SERVICES | Prohibited and Non-Covered Services 195
VAB description;
o If a revision to an existing VAB, include a summary of the change;
Category or group of enrollees eligible to receive the VAB if it is not appropriate for all enrollees;
Any limitations or restrictions that apply;
Types of providers responsible for providing the benefit or service, including any limitations on provider
capacity if applicable;
How and when providers and enrollees will be notified about the availability of such VAB;
How an enrollee may obtain or access the VAB;
o If a new financial incentive, include the mechanism itself (e.g., gift card, prepaid debit card) and
confirmation that it is not convertible to cash;
How the VAB will be identified in administrative data or encounter data;
PMPM actuarial value; and
Effective date.
Each submission must include a written certification that the VAB does not violate the Anti-Kickback statute (42
U.S.C. § 1320a-7b[b]) and its implementing regulations, the Beneficiary Inducement statute (42 U.S.C. § 1320a-
7a[a][5]) and its implementing regulations, and any other applicable provisions.
The MCO shall also provide the PMPM actuarial value and statement of commitment on an annual basis in
accordance with the Contract.
PROHIBITED AND NON-COVERED SERVICES
The MCO shall ensure that physicians and all other professionals abide by the professional guidelines set forth by
their certifying and licensing agencies in addition to complying with Louisiana Medicaid regulations.
In general, services that are not approved by the Food and Drug Administration or services that are experimental,
investigational, or cosmetic are excluded from Medicaid coverage and will be deemed not medically necessary.
The following non-exhaustive list of services excluded from MCO covered services and/or otherwise limited by
Louisiana Medicaid shall be reflected in the MCO’s coverage policy:
Any service (drug, device, procedure, or equipment) that is not medically necessary;
Experimental/investigational drugs, devices, procedures, or equipment, unless approved by the Secretary
of LDH;
Cosmetic drugs, devices, procedures, or equipment;
Assistive reproductive technology for treatment of infertility;
Elective abortions (those not covered in the Louisiana Medicaid State Plan) and related services;
Surgical procedures discontinued before completion;
Harvesting of organs when a Louisiana Medicaid enrollee is the donor of an organ to a non-Medicaid
enrollee; and
Provider preventable conditions, described below.
MCO Manual | SERVICES | Prohibited and Non-Covered Services 196
Provider Preventable Conditions
Louisiana Medicaid is mandated to meet the requirements of 42 C.F.R. § 447.26 with respect to non-payment for
provider preventable conditions (PPCs). The MCO is required to implement procedures for non-payment for these
events when applicable to its enrollees.
PPCs are defined into two separate categories:
Health care-acquired condition (HCAC), meaning a condition occurring in any inpatient hospital setting,
identified as a hospital acquired condition (HAC) in accordance with 42 C.F.R. § 447.26; and
Other provider preventable condition (OPPC), meaning a condition occurring in any health care setting in
accordance with 42 C.F.R. § 447.26.
The MCO shall not impose a reduction in reimbursement for a PPC when the condition defined as a PPC for a
particular enrollee existed prior to the initiation of treatment for the enrollee by that provider.
Reductions in provider reimbursement may be limited to the extent that the following apply:
The identified PPCs would otherwise result in an increase in reimbursement.
It is practical to isolate for non-payment the portion of the reimbursement directly related to treatment
for, and related to, the PPC.
Non-payment of PPCs shall not prevent access to services for Medicaid enrollees.
Health Care-Acquired Conditions
Refer to the CMS website for the current listing of HACs and associated diagnoses [link].
NOTE: Louisiana Medicaid considers HACs as identified by Medicare, other than deep vein thrombosis (DVT)/pulmonary
embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.
It is the responsibility of the MCO to determine if the HCAC was the cause for any additional days added to the
length of stay. The MCO may not reimburse for services related to HCAC.
Medicaid will require the Present-on-Admission (POA) indicators as listed below with all reported diagnosis codes.
POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an
outpatient encounter, including emergency department, observation or outpatient surgery, are considered as
present on admission.
Present on Admission Reporting Options:
Code
Definition
Y
Present at the time of inpatient admission
N
Not present at the time of inpatient admission
U
Documentation is insufficient to determine if condition is present on admission
W
Provider is unable to clinically determine whether condition was present on admission or not
Refer to the CMS website for the current listing of diagnoses that are exempt from POA reporting requirements
[link
].
MCO Manual | SERVICES | Prohibited and Non-Covered Services 197
Other Provider Preventable Conditions
MCOs are prohibited from reimbursing providers for the following OPPCs in any setting:
Wrong surgical or other invasive procedure performed on a patient;
Surgical or other invasive procedure performed on the wrong body part; or
Surgical or other invasive procedure performed on the wrong patient.
The MCO shall not reimburse for any days that are attributable to the OPPC. The diagnosis codes that are utilized
for the three OPPCs listed above are included below.
Y65.51 — Performance of wrong operation (procedure) on correct patient (existing code)
Y65.52 — Performance of operation (procedure) on patient not scheduled for surgery
Y65.53 — Performance of correct operation (procedure) on wrong side/body part
Outpatient Hospital Claims
In the event an outpatient surgery is performed erroneously, as described below, the appropriate modifiers to all
lines related to the erroneous surgery/procedure are:
PC: Wrong Surgery on Patient;
PB: Surgery Wrong Patient; or
PA: Surgery Wrong Body Part;
In summary, it is the responsibility of the provider to identify and report (through the UB-04) any PPC and not
seek reimbursement from Medicaid for any additional expenses incurred as a result of the PPC. The MCO may
disallow or reduce provider reimbursements based on a post-payment review of the medical record.
It is the responsibility of the MCO to ensure that reimbursement is not made for any expense as a result of a PPC.
MCO Manual | CARE MANAGEMENT 198
PART 5: CARE MANAGEMENT
The MCO shall design a comprehensive care management program to support enrollees, regardless of age, based
on individualized assessment of care needs.
INDEPENDENT EVALUATIONS FOR PASRR LEVEL II
The MCO shall be responsible for conducting PASRR Level II evaluations of enrollees upon referral from LDH.
Referrals will be based upon the need for an independent evaluation to determine the need for nursing facility
services and/ or the need for specialized services to address mental health issues while the enrollee is in a nursing
facility. This evaluation shall include those individuals with a dual SMI and ID/DD condition, though it does not
include individuals with only an OCDD Statement of Approval; there is a separate determination process outside
of the Contract for these evaluations.
In conducting the evaluation, the MCO shall follow the criteria set forth in 42 C.F.R. §§ 483.100 - 138 and shall
utilize the PASRR Level II standardized evaluation form provided by LDH.
Evaluators may use relevant evaluative data, obtained prior to initiation of PASRR, if the data are considered valid
and accurate and reflect the current functional status of the individual. However, if necessary to supplement and
verify the currency and accuracy of existing data, the evaluator shall gather additional information necessary to
assess proper placement and treatment. For those individuals without sufficient documentation to establish the
validity of a primary dementia diagnosis, this may include authorizing additional professional evaluation to ensure
appropriate diagnosis and differentiation.
In order to comply with federally mandated timelines, the MCO shall submit the completed Level II evaluation
report to OBH within four calendar days of receipt of the referral from LDH.
All screenings and evaluations shall begin with the presumption that individuals can live in community-based
residences. In conducting Level II evaluations, the MCO shall ensure that recommendations focus on ensuring the
least restrictive setting appropriate with the appropriate services, including case management services as
described in the Contract. The MCO shall ensure that these recommended services are offered to the enrollee.
This evaluation will confirm whether the individual has SMI and will detail with specificity the services and
supports necessary to live successfully in the community. It shall address options for where the individual might
live in the community. Additionally, the MCO shall ensure that all individuals applying for nursing facility services
are provided with information about community options.
When LDH determines that nursing facility services are not appropriate, the MCO shall assist eligible enrollees to
obtain appropriate alternative behavioral health services available under the Contract.
If at any time, the MCO identifies or becomes aware of an enrollee with serious mental illness (SMI) that is residing
in a nursing home who has an SMI but who has not received a Level II determination, the MCO shall notify LDH,
and shall conduct the evaluation upon request by LDH.
MCO Manual | CARE MANAGEMENT 199
PASRR TRACKING
The MCO shall track enrollees who went through the PASRR process, those residing in a nursing facility (NF), those
identified with SMI, and those receiving specialized services as per 42 C.F.R. § 483.130. Additionally, the MCO
shall track enrollees who are offered and are receiving case management services as well as those who are
diverted from NF placement.
The MCO shall track and report quarterly to LDH the delivery of all PASRR specialized behavioral health services
as defined and required under 42 C.F.R. § 483.120 and the DOJ Settlement Agreement.
The MCO shall advise OBH and Medicaid on any barriers to completing the PASRR evaluations or tracking process.
The MCO shall notify OBH as outlined in the LDH-issue reporting template of any problems or issues with the
PASRR process.
MCO shall retain records of the PASRR process for 10 years in order to support OBH determinations, and to protect
the individual’s appeal rights as per 42 C.F.R. § 483.130.
SERVICES TO COMPLY WITH THE DOJ AGREEMENT
The MCO shall support LDH in its compliance with the Department’s agreement with the United States
Department of Justice (DOJ) to reduce reliance on nursing facility-based care for individuals with SMI. This
includes, but is not limited to, providing assistance to LDH in executing the DOJ Agreement Implementation Plan,
the development of a statewide crisis plan for individuals with SMI, and performing a service system gap analysis.
The MCO shall assist LDH to identify enrollees with SMI who are receiving facility-based care, as well as those who
are at risk of nursing facility placement. The MCO shall ensure that the enrollee is receiving all necessary
behavioral health services within that nursing facility and to support the development of a care transition plan,
where appropriate. For the diversion population, the MCO shall ensure those at risk of nursing facility placement
are provided adequate services while in the community in an effort to ensure their needs are met and the need
for a higher level of care is mitigated whenever possible. Care transition plans shall include case management for
the enrollees upon transition for at least a 12-month period.
The MCO shall help identify and provide community based behavioral health services and service models to
support reduction of use of facility-based care for individuals with SMI, by developing a robust provider network
that can successful serve enrollees in the community.
WOMEN, INFANT, AND CHILDREN (WIC) PROGRAM
REFERRAL
The MCO shall refer of potentially eligible women, infants, and children and report appropriate medical
information to the WIC Program. A sample referral/release of information form is found in the Resources section.
MCO Manual | POPULATION HEALTH AND SOCIAL DETERMINANTS OF HEALTH 200
PART 6: POPULATION HEALTH AND SOCIAL
DETERMINANTS OF HEALTH
The population health approach seeks to maintain and improve the health status of the entire population through
prevention, while systematically identifying subpopulations with complex needs and implementing strategies to
improve status and reduce health inequities among subpopulations.
The MCO shall encourage and train providers to include Z codes in the ICD-10 CM on claims in order to track
factors influencing health status and not for use in determining payment.
STAFFING ROLES AND RESPONSIBILITIES
As part of the Population Health Strategic Plan, the MCO shall ensure that CHWs, supervisors, and program
directors successfully complete training on the following core competencies relevant to their roles.
Community Health Worker
o Adherence to intervention: Follows work practice manual for providing social support, care
coordination, advocacy, etc. for patients
o Organization: Utilizes tools to plan work and manage time (e.g. to-do list, calendar)
o Explanation of role: Accurately describes CHW role to patients and other members of care team
o Safety: Follows safety protocol set by organization (e.g. alerts supervisor when beginning/ending
home visits)
Supervisor
o Adherence to intervention: Adheres to work practice manual for CHW Supervisors, including best
practices for one-on-one CHW supervision (e.g. caseload review)
o Organization: Utilizes tools to plan work and mange time
o Explanation of program: Effectively describes the CHW role to care teams
o Safety: Follows safety protocol set by organization (e.g. ensures CHWs check-out of home visits)
o Performance assessments: Uses CHW performance reports to understand challenges and coach
to improve results
o Team leadership: Facilitates dynamic and engaging team meetings with ample CHW participation
Program Director
o Knowledge of intervention: Knowledge of work practice manuals for CHWs and CHW Supervisors
o Organization: Utilizes tools to plan work and manage time
o Explanation of program: Compellingly describes program design, goals, structure and results to
partner organizations
o Safety: Follows safety protocol set by organization (e.g. meets with CHWs who express safety
concerns)
o Performance assessment: Aggregates and analyzes CHW performance reports to ensure quality
across the program
o Enrollment targets: Sets and manages to quarterly patient enrollment goals; troubleshoots issues
to stay on track
MCO Manual | POPULATION HEALTH AND SOCIAL DETERMINANTS OF HEALTH 201
o Organizational change: Manages process for revising work practice manuals and ensures uptake
of changes across organization
o CHW hiring: Articulates desired CHW characteristics and leads hiring process to assess for these
elements
MCO Manual | PROVIDER CLAIMS & REIMBURSEMENT 202
PART 7: PROVIDER CLAIMS &
REIMBURSEMENT
The MCO shall administer an effective, accurate and efficient claims processing system that adjudicates provider
claims for covered services that are fulfilled within the timeframes specified in the Contract and the Manual.
LDH is responsible for setting and defining minimum provider rates for Medicaid covered services. The MCO shall
reimburse providers at an amount that is no less than the published Medicaid FFS rate or that is contained on the
weekly procedure file sent to the MCO by the fiscal intermediary in effect on the date of service unless mutually
agreed to by both the MCO and the provider. Nothing herein shall restrict the MCO from reimbursing at a higher
rate than would be reimbursed by Medicaid FFS.
Required data elements are provided in the MCO System Companion Guide.
EXCEPTIONS TO CLAIMS TIMELY FILING GUIDELINES
MCOs must comply with the following exceptions to the 365-day timely filing guidelines:
Administrative Error: This is where the failure to meet the filing deadline is caused by error or
misrepresentation of the MCO, its subcontractor, or LDH. In these cases, the MCO shall extend the timely
filing through the last day of the sixth month following the month in which the enrollee, provider, or
supplier received notice from the MCO that an error or misrepresentation was corrected.
Retroactive Medicaid entitlement or retroactive MCO enrollment: This is where a beneficiary receives
notification of Medicaid entitlement and/or MCO enrollment retroactive to or before the date the service
was furnished. In these cases the MCO shall extend timely filing to 365 calendar days from the date of
service or 180 calendar days from the enrollee’s linkage add date in the enrollee’s 834 eligibility file,
whichever is later.
ADJUSTMENTS AND VOIDS
The MCO may adjust or void incorrect claims payments.
The MCO may adjust or void incorrect claims payments electronically or hard copy. Adjustments/voids must be
submitted on the correct adjustment/void forms.
Only one internal control number (ICN) should be adjusted or voided on each form.
Only a paid claim can be adjusted or voided.
For purposes of MCO reporting on payment to providers, an adjustment to a paid claim shall not be counted as a
claim and electronic claims shall be treated as identical to paper based claims.
MCO Manual | PROVIDER CLAIMS & REIMBURSEMENT 203
INTEREST PAYMENTS
Interest owed to the provider must be reported on the encounter submission to the fiscal intermediary as defined
in the MCO System Companion Guide.
PAYMENT RECOUPMENTS
The MCO may recoup provider payments for a variety of reasons, including, but not limited to, the following:
Retroactive enrollment or disenrollment due to Medicaid or Medicare eligibility changes;
Discovery of improper payments through either of the following reviews:
o Automated review (i.e., analysis of paid claims) up to one year from the date of payment;
o Complex review (i.e., requires review of medical, financial, and/or other records) up to five years
from date of service; or
Third party liability.
The MCO shall not recoup payments simply on the basis of an encounter being denied. The MCO may submit
inquiries about encounter denials using the MMIS Inquiry Form as outlined in the MCO System Companion Guide.
The MCO should refer to the Eligibility and Enrollment and Third Party Liability sections of this Manual as well as
the Contract for additional requirements, including provider notification requirements.
FQHC/RHC CONTRACTING AND REIMBURSEMENT
Behavioral health services provided in a FQHC or RHC may be reimbursed via the Prospective Payment System
(PPS) rate, when provided by approved practitioner types as established in the Medicaid FQHC Provider Manual
(e.g., psychiatrists, licensed clinical psychologists, psychiatric nurse practitioners, and licensed clinical social
workers), and in accordance with established FQHC/RHC Medicaid rules, policies and manuals.
Mental Health Rehabilitation (MHR) State Plan services may be provided by an FQHC or RHC under the following
conditions:
The FQHC/RHC has HRSA approval to provide ambulatory MHR services;
Services are provided by a psychiatrist, licensed clinical psychologist or licensed clinical social worker;
Services are delivered in accordance with the State Plan, as well as all federal and state laws; and
Services are billed via the all-inclusive PPS rate.
FQHCs or RHCs providing MHR services outside of the above established parameters may not be reimbursed with
Medicaid funding for these services. Such entities desirous of providing MHR services must enroll separately with
the MCO as an appropriate Behavioral Health Service Provider (BHSP) type with a unique National Provider
Identifier (NPI), be licensed as a BHSP issued by LDH Health Standards, and bill in accordance with the SBHS
Medicaid rules, policies and manuals.
MCO Manual | ENCOUNTERS 204
PART 8: ENCOUNTERS
The MCO shall submit encounter data according to specifications, including data elements and reporting
requirements, outlined in the MCO System Companion Guide
The MCO shall submit paid, denied, adjusted, and voided claims with the appropriate identifiers established in the
MCO System Companion Guide to indicate these claims as encounters.
The MCO should refer to the MCO System Companion Guide for a list of encounter edit codes.
CLAIMS SUMMARY REPORT
The MCO must submit monthly Claims Summary Reports of paid and denied claims to LDH by claim type per
instructions in the MCO System Companion Guide.
ENCOUNTERS GREATER THAN $1 MILLION
For non-hospital encounters that are greater than $1 million, the MCO shall:
1. Send the claim as a single encounter.
2. On the encounter, split the dollar amount across the coordination of benefit (COB) loops, with
each loop having the MCO’s carrier code. The MCO can submit up to three COB loops in this
way, and the dollar amount should be split across the loops. For example, if the total dollar
amount is $2,500,000, the MCO should populate three COB loops with the following billed
charges amounts:
a. First loop = 999,999.99;
b. Second loop = 999,999.99;
c. Third loop = 500,000.02.
3. 3. Ensure that the billed charges amount does not exceed 999,999.99 per COB loop.
The MCO should refer to the MCE System Companion Guide for additional details regarding COB loops.
PHARMACY ENCOUNTERS
The MCO shall submit a weekly claim-level detail file of pharmacy encounters to LDH which includes individual
claim-level detail information on each pharmacy claim dispensed to a Medicaid patient, including but not limited
to the total number of metric units, dosage form, strength and package size, National Drug Code of each covered
outpatient drug dispensed to Medicaid enrollees. See the Batch Pharmacy Encounters Companion Guide for a
complete listing of claim fields required.
Disputed Pharmacy Encounter Submissions
Within 60 calendar days of receipt of the disputed encounter file from LDH, the MCO shall, if needed, correct and
resubmit any disputed encounters and send a response file that includes 1) corrected and resubmitted encounters
MCO Manual | ENCOUNTERS 205
as described in the Rebate Section of the Batch Pharmacy Encounters Companion Guide and/or 2) a detailed
explanation of why the disputed encounters could not be corrected including documentation of all attempts to
correct the disputed encounters at an encounter claim level detail, as described in the Rebate Section.
340B Claim Level Indicators
Carve In Pharmacy Claims: On 340B claims, a value of “20” in NCPDP field 420-DK (Submission Clarification
Code) and a value of “8” in NCPDP field 423-DN (Basis of Cost Determination) shall be submitted in the
pharmacy claim segment of a billing transaction.
Professional Services Claims (Physician- Administered Drug Claims): Physician-Administered drug claims
shall use the UD modifier to identify 340B drugs on outpatient physician-administered drug claims.
Carve-Out Claims: Covered entities who carve out Medicaid beneficiaries shall bill according to guidelines
provided in each plan’s provider manual.
SKILLED NURSING FACILITIES ENCOUNTER CLAIMS
This guidance is regarding the bill type to capture the reimbursement of skilled nursing facilities as an in lieu of
service.
The fiscal intermediary is currently rejecting encounters for skilled nursing facilities when MCOs use bill type 21x.
Therefore, LDH is authorizing MCOs to amend the bill type when submitting the encounters for skilled nursing
facilities that are medically appropriate and a cost effective alternative to an inpatient hospital stay, to bill type
11x (instead of bill type 21x). By taking this action, these encounters will be captured as inpatient skilled nursing
facility encounter claims.
MCO Manual | PROVIDER NETWORK 206
PART 9: PROVIDER NETWORK
The MCO must develop, maintain, and monitor its provider network to ensure the availability and accessibility of
MCO covered services as required by the Contract. This includes, but is not limited to, complying with geographic
access, and appointment and wait times for enrollees.
AVAILABILITY AND ACCESSIBILITY REQUIREMENTS
The MCO shall submit quarterly reports in the format specified by LDH documenting the geographic availability of
network providers including PCPs, hospitals, pharmacies, and each specialty type listed in the Contract and herein.
The MCO’s network assessment shall compare the distribution of enrollees to the distribution of providers by
region and parish, considering urban and rural standards as specified by LDH.
The MCO shall submit reports documenting the geographic availability of network providers including PCPs,
hospitals, pharmacies, and each specialty type listed below.
Specialty
Louisiana Medicaid
Provider Specialty
NPPES Taxonomy
Code
Primary Care Providers
Family Practice
8
207Q00000X
FQHCs
42
261QF0400X
General Practice
1
208D00000X
Internal Medicine PCPs
41
207R00000X
Nurse Practitioners
79
363L00000X
OB/GYN PCPs
16
207V00000X
Pediatrics
37
208000000X
Rural Health Clinics
94
261QR1300X
Ancillary Services
Ambulance Service Supplier
59
341600000X
Dialysis Centers
n/a
261QE0700X
Durable Medical Equipment
n/a
332B00000X
Home Health
n/a
251E00000X
Infusion Therapy
n/a
261QE0700X
NEMT - Non-profit
45
343900000X
NEMT – Profit
46
343900000X
Urgent Care Clinics
7N
261QU0200X
Hospitals
Hospitals - General Acute Care
86
282N00000X
Hospitals - Children's
86
282NC2000X
Hospital - Rehabilitation
86
283X00000X
Pharmacies
Pharmacies
n/a
333600000X
Specialty
Adolescent Medicine
1A
2080A0000X
Allergy
3
207K00000X
Anesthesiology
5
207L00000X
Audiologist
64
231H00000X
Cardiac Electrophysiology
2A
207RC0001X
Cardiovascular Disease
6
207RC0000X
MCO Manual | PROVIDER NETWORK 207
Cardiovascular Disease
2B
207RC0000X
Chiropractor
35
111N00000X
Clinic or Other Group Practice
70
261QM1300X
Critical Care Medicine
2C
207RC0200X
Critical Care Medicine
3A
207RC0200X
Dermatology
7
207N00000X
Diagnostic Laboratory
72
293D00000X
Emergency Medicine
1T
207P00000X
Endocrinology & Metabolism
2E
207RE0101X
Family Practice
8
207Q00000X
Gastroenterology
10
207RG0100X
Gastroenterology
2F
207RG0100X
General Practice
1
208D00000X
General Surgery
2
208600000X
Geriatric Medicine
2G
207RG0300X
Geriatrics
38
207RG0300X
Gynecologic oncology
3B
207VX0201X
Hand Surgery
40
2086S0105X
Hematology
2H
207RH0000X
Independent Laboratory
69
291U00000X
Indiv Certified Prosthetist - Ortho
57
225000000X
Infectious Disease
2I
207RI0200X
Internal Medicine
41
207R00000X
Licensed Clinical Social Worker
73
1041C0700X
Maternal & Fetal Medicine
3C
207VM0101X
Med Supply / Certified Orthotist
51
222Z00000X
Med Supply / Certified Prosthetist
52
224P00000X
Medical Oncology
2J
207RX0202X
Neonatal Perinatal Medicine
1C
2080N0001X
Nephrology
39
207RN0300X
Nephrology
2K
207RN0300X
Neurological Surgery
14
207T00000X
Neurology
13
2084N0400X
Nuclear Medicine
2Q
207UN0903X
Nurse Practitioner
79
363L00000X
OB/GYN
16
207V00000X
Occupational Therapy
74
225X00000X
Ophthalmology
18
207W00000X
Optician / Optometrist
88
156FX1800X
Orthodontist
19
1223X0400X
Orthopedic Surgery
20
207X00000X
Otology, Laryngology, Rhinology
4
207W00000X
Pathology
22
207ZP0102X
Pediatric Cardiology
1D
2080P0202X
Pediatric Critical Care Medicine
1E
2080P0203X
Pediatric Day Health Care
1Z
261QM3000X
Pediatric Emergency Medicine
1F
2080P0204X
Pediatric Endocrinology
1G
2080P0205X
Pediatric Gastroenterology
1H
2080P0206X
Pediatric Hematology - Oncology
1I
2080P0207X
Pediatric Infectious Disease
1J
2080P0208X
MCO Manual | PROVIDER NETWORK 208
Pediatric Nephrology
1K
2080P0210X
Pediatric Pulmonology
1L
2080P0214X
Pediatric Rheumatology
1M
2080P0216X
Pediatric Sports Medicine
1N
2080S0010X
Pediatric Surgery
1P
2086S0120X
Pediatrics
37
208000000X
Physical Medicine Rehabilitation
25
208100000X
Physician Assistant
2R
363A00000X
Plastic Surgery
24
208200000X
Podiatric Surgery
48
213ES0131X
Proctology
28
208C00000X
Psychiatry
26
2084P0800X
Pulmonary Disease
2L
207RP1001X
Pulmonary Diseases
29
207RP1001X
Radiology
30
2085R0202X
Rheumatology
2M
207RR0500X
Rural Health Clinic
94
261QR1300X
Speech Therapy
71
235Z00000X
Surgery - Critical Care
2N
2086S0102X
Surgery - General Vascular
2P
2086S0129X
Thoracic Surgery
33
208G00000X
Urology
34
208800000X
Specialized Behavioral Health
APRN – Clinical Nurse Specialist
26
See MCO System
Companion Guide
APRN – Nurse Practitioner
26
See MCO System
Companion Guide
Assertive Community Treatment
8E
261QM0850X
Behavioral Health Rehab Agency
8E
See MCO System
Companion Guide
Center Based Respite
8E
See MCO System
Companion Guide
Certified Social Worker
LL
See MCO System
Companion Guide
Crisis Receiving Center
8E
See MCO System
Companion Guide
Distinct Part Psychiatric Unit
86
273R00000X
Federally Qualified Health Center
42
261QF0400X
Freestanding Psychiatric Hospital
86
283Q00000X
Licensed Addiction Counselor
8E
101YA0400X
Licensed Clinical Social Worker
73
See MCO System
Companion Guide
Licensed Marriage Family Therapist
8E
See MCO System
Companion Guide
Licensed Master Social Worker
LL
See MCO System
Companion Guide
Licensed Professional Counselor
8E
See MCO System
Companion Guide
Medical Psychologist
6G
See MCO System
Companion Guide
Mental Health Clinic (LGEs)
70
See MCO System
Companion Guide
MCO Manual | PROVIDER NETWORK 209
Mental Health Rehab Agency (Legacy)
78
See MCO System
Companion Guide
Multi-Systemic Therapy Agency
5M
See MCO System
Companion Guide
Physician Assistant
26
See MCO System
Companion Guide
Psychiatric Residential Treatment Facility
9B
See MCO System
Companion Guide
Psychiatric Residential Treatment Facility – Addiction Specialty
8U
See MCO System
Companion Guide
Psychiatric Residential Treatment Facility – Other Specialty
8R
See MCO System
Companion Guide
Psychiatrist
26
See MCO System
Companion Guide
Psychiatrist - Addictionologist
2W
See MCO System
Companion Guide
Psychologist – Clinical
6A
See MCO System
Companion Guide
Psychologist – Counseling
6B
See MCO System
Companion Guide
Psychologist – Developmental
6D
See MCO System
Companion Guide
Psychologist – Non-Declared
6E
See MCO System
Companion Guide
Psychologist – Other
6F
See MCO System
Companion Guide
Psychologist – School
6C
See MCO System
Companion Guide
Psychology Intern
LL
See MCO System
Companion Guide
Provisionally Licensed Marriage and Family Therapist
LL
See MCO System
Companion Guide
Provisionally Licensed Professional Counselor
LL
See MCO System
Companion Guide
Rural Health Clinic (Independent)
94
261QR1300X
Rural Health Clinic (Provider Based)
94
261QR1300X
School Based Health Center
70
261QH0100X
Substance Abuse & Alcohol Abuse Center (Outpatient)
70
See MCO System
Companion Guide
Substance Use Residential Treatment Facility
8U
See MCO System
Companion Guide
Therapeutic Foster Care Agency
9F
See MCO System
Companion Guide
Therapeutic Group Home
5X
See MCO System
Companion Guide
The MCO’s network assessment shall compare the distribution of enrollees to the distribution of providers by
region and parish, considering urban and rural standards as specified by LDH.
The data in the network adequacy reports shall be current, accurate, and consistent with the Contract and this
Manual.
MCO Manual | PROVIDER NETWORK 210
The MCO’s attestation included with geographic availability reports shall identify deficiencies in its provider
network by parish and type of service as well as specific tasks that the MCO will take to mitigate and work to
eliminate each identified network deficiency by adding qualified, contracted network providers. The MCO must
also identify and address gaps in provider network accessibility in the Network Development and Management
Plan along with the MCO’s approach to remedy such gaps.
PROVIDER ENROLLMENT
Other Enrollment and Disenrollment Requirements
The MCO shall require unlicensed staff of provider organizations rendering and receiving reimbursement for
Mental Health Rehabilitation (MHR) services to obtain and submit National Provider Identifier (NPI) numbers to
the MCO, as well as documentation verifying the unlicensed staff meets all qualifications and requirements for
providing mental health rehabilitation (MHR) services established by State law, rules, regulations, State Plan,
waivers, the Medicaid Behavioral Health Services Provider Manual, and the Contract, inclusive of Evidence-Based
Program (EBP) MHR services, with the exception of Assertive Community Treatment (ACT), which is paid at a per
diem rate, prior to reimbursing agencies for services provided by these staff. Claims submitted for MHR services
shall include rendering provider NPIs and other MCO required identifiers regardless of whether the rendering staff
is licensed or unlicensed. The MCO shall configure systems to deny claims for services when rendering providers
and NPIs are denoted on claims for service that have not been credentialed by the State and approved by the
MCO. The MCO shall submit their policies, procedures and a detailed work plan associated with this requirement
as a part of the readiness review to LDH for approval. The MCO’s work plan shall include timelines associated
with systems configuration, systems testing phases, education and outreach to providers, communication notices
to providers, and the effective date the MCO’s unlicensed staff NPI requirement will go live.
CREDENTIALING AND RE-CREDENTIALING OF PROVIDERS
AND CLINICAL STAFF
The MCO shall provide information to the State’s provider management contractor on contracted providers in
accordance with the MCO System Companion Guide.
See the Resources section for a link to the Louisiana Standardized Credentialing Application.
Specialized Behavioral Health Providers
Prior to contracting via a provider agreement or single case agreement (SCA), or prior to reimbursing for
specialized behavioral health services (SBHS), the MCO shall credential providers to ensure provider facilities,
organizations, and staff meet all qualifications and requirements established by LDH policy, including, but not
limited to, the Behavioral Health Services Provider Manual chapter of the Medicaid Services Manual, state and
federal laws, and rules and regulations for all specialized behavioral health providers. MCO credentialing files on
providers shall include verification of meeting said requirements. This shall include that agencies offering mental
health rehabilitation services (CPST, PSR, and/or CI), Assertive Community Treatment (ACT), Crisis Response
Services (MCR, CBCS, BHCC, and/or CS), PRTFs, TGHs, SUD residential addiction treatment facilities, and Opioid
MCO Manual | PROVIDER NETWORK 211
Treatment Programs supply proof of accreditation by an LDH approved accrediting body, which shall be made part
of the agency’s credentialing file with the MCO. Agencies, facilities or organizations not accredited at the time of
credentialing shall supply proof that they applied for accreditation and paid the initial application fee. Agencies
must present proof of full accreditation within the required timeframe established by LDH policy, including, but
not limited to, the Behavioral Health Services Provider Manual chapter of the Medicaid Services Manual.
Specialized behavioral health provider types required to be accredited by rule, regulation, state or federal law, or
waiver or State Plan Amendment (SPA) prior to contracting or prior to receiving Medicaid reimbursement, shall
have proof of accreditation on file with the MCO prior to receiving reimbursement from the MCO. LDH approved
national accrediting bodies include:
The Council on Accreditation (COA);
The Commission on Accreditation of Rehabilitation Facilities (CARF); or
The Joint Commission (TJC).
Prior to subcontracting via a provider agreement or single case agreement (SCA), or prior to reimbursing for
specialized behavioral health services (SBHS), the MCO shall credential providers to ensure they meet
requirements of the Behavioral Health Services Provider Manual chapter of the Medicaid Services Manual,
inclusive of, but not limited to, holding required licensure and accreditation. The MCO shall credential Certified
Peer Support Specialists and rendering providers of MHR services to ensure they meet requirements established
by state and federal law, regulation, waivers, SPA and the Medicaid Behavioral Health Services Provider Manual
prior to entering into provider agreements or reimbursing providers for peer support or MHR services.
Contracting of Behavioral Health Providers
The MCO shall enter into written agreements with qualified behavioral health service providers to deliver covered
behavioral health services to enrollees. The contract shall specify the activities, services and reporting
responsibilities delegated to the provider; and provide for revoking delegation, terminating contracts, or imposing
other sanctions if the provider’s performance is inadequate.
Upon request, LDH shall be given copies of any subcontracts entered into by the MCO regarding behavioral health
services, including provider agreements. Any proprietary information regarding rate setting may be redacted by
the MCO.
All behavioral health provider agreements shall include the following provisions:
The name and address of the subcontracted behavioral health provider.
The method and amount of compensation, reimbursement, payment, and other considerations provided
to the behavioral health provider.
Identification of the population to be served by the behavioral health provider, including the number of
members the provider is expected to serve.
The amount, duration, and scope of covered behavioral health services to be provided.
The provider’s treatment site shall be a smoke-free environment.
The term of the provider agreement, including beginning and ending dates, and procedures for extension,
termination, and renegotiation.
The provider is responsible for ensuring any patient data (including data for the uninsured populations)
required by the MCO is provided through an EHR interface or an ongoing data file submission.
MCO Manual | PROVIDER NETWORK 212
Specific behavioral health provider duties relating to coordination of benefits and determination of third-
party liability.
Identification of Medicare and other third-party liability coverage and requirements for seeking Medicare
or third-party liability payments before submitting claims and/or encounters to MCO, when applicable.
Maintenance of an appropriate clinical record keeping system that ensures appropriateness of billing.
A requirement that contracted, allowable prescribing providers shall utilize the electronic Medicaid
Clinical Data Inquiry (e-CDI) system (accessible via www.lamedicaid.com) to perform medication searches
within the member’s medical history to ensure that appropriate medication management is conducted.
Compliance with the requirements in the MCO QAPI and UM plans/program including PIP and Corrective
Action Plans.
Language that requires a written contract amendment and prior approval of LDH, if the provider
participates in any merger, reorganization, or changes in ownership or control, that is related to or
affiliated with the MCO.
The HIPAA Business Associate Addendum.
Assumption of full responsibility for all tax obligations, worker's compensation insurance, and all other
applicable insurance coverage obligations required in the Contract, for itself and its employees, and that
LDH shall have no responsibility or liability for any taxes or insurance coverage.
Incorporation by reference of the Behavioral Health Services Provider Manual chapter of the Medicaid
Services Manual, electronic access to the Behavioral Health Services Provider Manual chapter, the MCO’s
Provider Manual and language that requires the behavioral health provider comply with all requirements
stated in the Behavioral Health Services Provider Manual chapter in effect at the time of service provision,
the Contract and CMS approved waivers and SPA.
A requirement that all behavioral health network providers request a standardized release of information
from each member to allow the network provider to coordinate treatment with the member’s primary
care physician.
A requirement that the behavioral health provider notify the MCO when it is not accepting new clients,
or if it does not accept a client and the associated cause.
Compliance with encounter reporting and claims submission requirements in accordance with the
Contract (to be detailed in the MCO’s Provider Manual), including payment withhold provisions and
penalties for non-reporting, untimely reporting, or inaccurate reporting.
A provision that the MCO will not offset LDH recouped payments on the behavioral health provider after
LDH has verified that the MCO was at fault for the error in payment.
A requirement that behavioral health providers adopt the utilization management guidelines, and to
measure compliance with the guidelines.
The right of a provider to appeal a claims dispute in accordance with the Contract (to be detailed in the
MCO’s Provider Manual).
The provider shall be responsible for assisting enrollees in understanding their right to file grievances and
appeals in accordance with the MCO’s Provider Manual. The MCO must provide the information specified
at 42 C.F.R. § 438.10(g)(2)(xi).
Compliance by the subcontractor or provider with audits, inspections and reviews in accordance with the
MCO’s Provider Manual, including any reviews the MCO or LDH may conduct.
Facilitation by the provider of another provider’s reasonable opportunity to deliver services, and the
prohibition of any commission or condoning of any act or omission by the provider or by state employees
that interferes with, delays, or hinders service delivery by another provider.
MCO Manual | PROVIDER NETWORK 213
Compliance with adverse incident reporting policy and standards approved by LDH.
Timely implementation by the provider of LDH and MCO decisions related to grievances, member appeals,
claims dispute or adverse incident mitigation recommendations.
Compensation to individuals or entities that conduct UM activities is not structured to provide incentives
for the individual or entity to deny, limit, or discontinue medically necessary services to any behavioral
health member, according to 42 C.F.R. § 438.210(e).
Submission to LDH and/or the MCO as determined by LDH of the National Outcome Measures, including
access to services, engagement in services, independent and stable housing, employment, and
employment training rates.
Members reaching the age of majority are provided continuity of care without service disruptions or
mandatory changes in providers.
The LDH definition of medically necessary covered behavioral health services and the LDH levels of care
are incorporated by reference.
A requirement that the providers assess the cultural and linguistic needs of the service area, and deliver
services that address these needs to the extent resources are available.
A requirement that the providers attend trainings on cultural competence. The MCO shall include a
cultural competency component in each training topic.
Language for supplying business transaction information upon request as required by 42 C.F.R. § 455.105.
The credentialing forms and provider agreements used by the MCO will require network providers to
disclose business transactions with wholly owned suppliers or any subcontractors upon request.
The MCO shall evaluate and make a determination to retain behavioral health providers utilizing performance and
QI data acquired while delivering services under the Contract.
The MCO shall clearly describe and disseminate the process and criteria to be used for terminating behavioral
health provider participation. If the MCO declines to subcontract with individuals or groups of behavioral health
providers as part of the network, it shall give the affected providers prior written notice of the reason for its
decision.
The MCO shall give written notice of termination of a subcontract provider, within fifteen (15) calendar days after
receipt of issuance of the termination notice, to each behavioral health member who received his or her care from
or was seen on a regular basis by the terminated provider.
Permanent Supportive Housing Providers
Because Louisiana’s Permanent Supportive Housing program is a cross-disability program, MCO contracted
providers delivering PSH services must meet the following requirements prior to, and as a condition of
maintaining, contracting and credentialing to provide tenancy supports for PSH program participants:
Fulfill the orientation, training, and annual review requirements required and delivered through the LDH
PSH program office;
Be approved for participation by the LDH PSH Program Director with oversight of the LDH PSH Executive
Management Committee;
Meet all requirements necessary to maintain credentialing to provide CPST;
Enroll to provide housing support services under the applicable 1915(c) HCBS waiver programs in FFS
Medicaid and/or managed long term supports and services.
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The MCO shall offer a provider agreement to all providers meeting the above requirements and approved by the
LDH PSH Program Director to participate in the Louisiana PSH program. The provider agreement must meet all
rate floor requirements, unless other terms are agreed to by both parties.
The MCO shall accept provider credentialing requests, review them for completeness, forward the request to the
LDH PSH program for review, approval of program participation, and maintain a roster and records of qualified
PSH providers.
At the request of the LDH PSH program the MCO shall assist the LDH PSH program in PSH provider certification
(fidelity) reviews, including the mutual sharing of MCO audit and PSH program monitoring reports for PSH
providers.
At the request of the LDH PSH program, the MCO shall assist in advertising PSH provider orientation to interested
providers in each region where there is a need to expand PSH as identified by the LDH PSH program.
PRIMARY CARE
PCP Automatic Assignment
The MCO shall, at a minimum, determine whether the assigned enrollee has received services through the MCO
within the previous year and if the enrollee has a provider-beneficiary relationship with a network PCP.
If the assigned enrollee was previously enrolled with the MCO, then the assignment shall be to the enrollee’s most
recent PCP if, in the MCO’s reasonable judgment, such assignment is appropriate.
If the assigned enrollee was not previously enrolled with the MCO, then the MCO shall make its best efforts to
seek and obtain pertinent information from the enrollee to assign the enrollee to an appropriate PCP, considering
all sources of information available to the MCO, including but not limited to, information provided by LDH or its
enrollment broker. The MCO shall, based on such information that it is able to obtain in a timely manner, take
into account factors that include, but are not limited to, the following:
The enrollee’s age and sex;
Available information on the enrollee’s healthcare needs, including behavioral health service needs;
PCP training and expertise with demographic or special populations similar to the enrollee, including
children in the care or custody of DCFS and homeless persons;
Geographical proximity of PCP site(s) to the enrollee’s residence;
Whether the PCP site is accessible by public transportation;
Whether the PCP site is accessible to people with disabilities;
The enrollee’s primary language and capabilities of the PCP to practice in that language and access to
skilled medical interpreters who speak the enrollee’s primary language at the PCP site; and
Whether an immediate family member is enrolled in the MCO and has a designated PCP or a provider-
beneficiary relationship that may be applicable to the enrollee.
If there is no enrollee or immediate family historical usage, enrollee shall be auto-assigned to a PCP using an
algorithm developed by the MCO, based on the age and sex of the enrollee, geographic proximity, and other
information on the enrollee and PCP that is available, such as language or access for persons with disabilities as
noted in this section.
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The MCO shall inform the enrollee of the name of the PCP to whom he or she is assigned and offer to assist the
enrollee in scheduling an initial appointment with the PCP.
The MCO shall routinely and promptly inform PCPs of newly assigned enrollees and shall require PCPs to make
best efforts to schedule an initial appointment with new enrollees.
The MCO shall submit to LDH for its review and prior approval a model assignment notification letter for enrollees
and an assignment notice for PCPs.
PCP Designation for Enrollees
The MCO shall submit a roster for each PCP the individual enrollees that are designated to that PCP’s panel to LDH
weekly in accordance with the MCO System Companion Guide. The MCO shall also make the roster available to
the PCP on the first day of each month via e-mail or provider portal. The roster shall include an easily identifiable
indicator if the enrollee is newly enrolled in the MCO and the method by which the enrollee was assigned (i.e., via
section or automatic assignment).
The provider to enrollee linkage ratio should not exceed 1:2,500 across the MCOs. LDH will notify each MCO if a
provider should be capped.
The MCO shall perform a quarterly claims analysis based on the previous 12 months of claims history to review
correct enrollee designation. If an enrollee has been seeing another PCP, the enrollee may be reassigned.
Enrollee Reassignment Policy
The MCO shall have an enrollee reassignment policy that complies with the following core elements to ensure
that enrollees are assigned to the most appropriate PCP. The policy shall include safeguards to prevent the
assigned PCP from “de-selecting” or “cherry picking” enrollees. The policy, and any revisions, shall be reviewed
and approved by LDH at least 30 calendar days prior to implementation.
The following core elements shall apply to all in-network PCPs, all enrollees who have been assigned to the current
PCP for at least 90 days, and enrollees who have not seen the assigned PCP within the prior 12 months.
The MCO should refer to the Contract for requirements related to the enrollee’s initial assignment.
Analysis
The MCO shall perform claims analysis on a quarterly basis and based on the previous 12 months (at minimum)
of claims history, including wellness visits and sick visits.
Reassignment
An enrollee will be eligible for reassignment if they have visited an unassigned PCP at least once within the
previous 12 months, as follows:
If the enrollee has seen an unassigned PCP within the same tax ID number (TIN) as the assigned PCP, the
enrollee will not be reassigned.
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If an enrollee has not seen the assigned PCP and has seen multiple unassigned PCPs, the enrollee will be
assigned to the PCP with the most visits.
o If the enrollee has the same number of visits with multiple unassigned PCPs, the enrollee will be
assigned to the most recently visited PCP.
If the enrollee has an established relationship, defined by at least one claim within the previous 12
months, with an unassigned PCP, the MCO will reassign that enrollee appropriately, even if the unassigned
PCP’s panel shows that it is closed. The enrollee-PCP relationship takes priority over a closed panel.
An enrollee will also be eligible for reassignment to another PCP under the following conditions:
if they have not visited any PCP within the previous 12 months.
If they are under 4 years of age and have not visited a PCP within the previous 6 months.
If they have not visited a PCP within 6 months of giving birth.
All reassignments shall be prospective. An enrollee who has been reassigned may be transferred to another PCP
upon enrollee request and in accordance with the Contract.
Provider Notification
MCOs must publish the results of the claims analysis to their provider portals on the 15
th
calendar day of the
second month of each quarter. If the due date falls on a weekend or a State-recognized holiday, the results shall
be published on the next business day.
The results shall identify all enrollees eligible for reassignment from the PCP along with enrollees eligible for
reassignment to the PCP. Enrollees identified as eligible for reassignment to the PCP shall be shared as
informational only considering this data is subject to change via the dispute protocol below.
The results of the analysis shall be published in a format that is able to be downloaded/exported into Excel. The
PCP is allowed 15 business days to review before any enrollees are reassigned.
MCOs must also include a protocol for provider disputes with the results from the claim analysis. To dispute the
reassignment of the enrollee(s) from the PCP, the provider must provide documentation (e.g., medical record,
proof of billed claim, etc. for at least one date of service) that they have seen the enrollee(s) during the previous
12 months.
MCOs must incorporate a flag for providers to identify new enrollees on their rosters/panels easily and a flag to
indicate if the enrollee was auto-assigned or not. This flag is for all enrollees, not just reassigned enrollees.
Enrollee Notification
MCOs must incorporate the process for notifying the affected enrollees within the policy.
LDH Notification
In accordance with the standard reporting deadlines established in the Contract, MCOs shall report the following
to LDH on a quarterly basis:
• Number of PCPs included in the analysis.
• Number of PCPs with at least one enrollee reassigned from their panel.
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• Number of PCPs with at least one enrollee reassigned to their panel.
• The name of any PCP that had no changes to their panel from the reassignment analysis.
Referral System for Specialty Health Care
The MCO shall have a referral system for MCO enrollees requiring specialty healthcare services to ensure that
services can be furnished to enrollees promptly and without compromise to care. The MCO shall provide the
coordination necessary for referral of MCO enrollees to specialty providers. The MCO shall assist a PCP or enrollee
with getting an appointment with the appropriate service provider. The referral system must include processes to
ensure monitoring and documentation of specialty health care and out-of-network referrals, services, and follow
up are included in the PCP’s enrollee medical record. The MCO must assist the PCP or enrollee with making an
appointment. Contact information for accessing referral system services should be clearly outlined in provider and
enrollee materials.
The MCO shall submit referral system policies and procedures for review and approval within 30 calendar days
from the date the Contract is signed, annually thereafter, and prior to any revisions. Referral policies and
procedures shall describe referral systems and guidelines and, at a minimum, include the following elements:
When a referral from the enrollee’s PCP is and is not required;
Process for enrollee referral to an out-of-network provider when there is no provider within the MCO's
provider network who has the appropriate training or expertise to meet the particular health needs of the
enrollee;
Process for providing a standing referral when an enrollee with a condition requires on-going care from a
specialist;
Process for assisting PCPs find specialists when their attempts have been unsuccessful. This process shall
include a form that can be faxed or securely e-mailed to the MCO, with a 72 hour turnaround to the
provider;
Process for referral for specialty care for an enrollee with a life-threatening condition or disease who
requires specialized medical care over a prolonged period of time;
Policy that prohibits providers from making referrals for designated health services to healthcare entities
with which the provider or an enrollee of the provider’s family has a financial relationship; and
Processes to ensure monitoring and documentation of specialty healthcare services and follow up are
included in the PCP’s enrollee medical record.
There must be written evidence of the communication of the patient results/information to the referring physician
by the specialty healthcare provider or continued communication of patient information between the specialty
healthcare provider and the primary care provider; and
Process for referral of enrollees for State Plan services that are excluded from MCO covered services and that will
continue to be provided through fee-for-service Medicaid.
The MCO shall develop electronic, web-based referral processes and systems.
ACCESS TO MEDICATION ASSISTED TREATMENT
The MCO shall refer to the Reporting section of this Manual for required MAT reporting.
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SPECIALIZED BEHAVIORAL HEALTH PROVIDERS
The MCO shall ensure its provider network offers a range of basic and specialized behavioral health services as
reflected herein and meets the network adequacy standards defined in the Contract. In addition, the MCO shall
develop, maintain, and monitor the provider network to ensure availability and accessibility of covered services
to specialized populations (e.g., pregnant women with mental health or substance use disorder needs and
adolescents with co-morbid behavioral health and intellectual disability needs). The provider network shall be
adequate for the anticipated number of enrollees for the service area.
The MCOs shall collaborate with each other to develop and implement a plan for monitoring specialized
behavioral health (SBH) providers and facilities across all levels of care, excluding inpatient psychiatric hospital
services, which incorporates onsite reviews, with a focus on unlicensed providers delivering care. The MCO shall
conduct network monitoring reviews on a sample of providers on at least a quarterly basis. The MCO shall submit
the plan to LDH for approval within 60 calendar days of the operational start date and at least 60 days prior to
material change. The MCO’s plan shall comply with all the requirements as specified by LDH:
Review criteria for each applicable service which comprehensively addresses:
o the adherence to minimum provider qualifications and requirements at the organizational level
and the individual staff level as established by Louisiana law, rules, regulations, SPA, waivers and
Medicaid provider policy manuals. This shall include but not be limited to requirements
associated with licensure, accreditation, educational and professional experience, and training
inclusive of utilization of LDH approved training curriculum in the delivery of services, if applicable,
as established by Medicaid provider policy manuals. Verification shall include review of provider
and staff personnel records and other administrative records.
o Adherence to appointment availability standards as established by this contract and as evidenced
by provider’s scheduling system and wait times for appointments and admission;
o Accuracy of provider demographics associated with service location addresses, telephone
numbers, languages spoken, current staff rosters and status of accepting new Medicaid referrals,
as compared against MCO credentialing files and the MCO provider directory listings; and
NOTE: Providers shall be reviewed based on the services for which they have received reimbursement.
Plan for updating review criteria based on changes to requirements as reflected in the applicable provider
manual or rule;
Number of staff personnel records to be reviewed at each provider location (the MCO shall review a
reasonable number of records to determine each provider’s compliance rate) and look-back period;
Onsite review criteria;
Sample selection criteria, including inclusion and exclusion criteria, and representative sample size;
Tools to be used;
Qualifications for staff performing monitoring reviews who at a minimum must receive annual training on
the LDH Behavioral Health Provider Manual and the relevant State laws, policies, and regulations related
to the State's mental health rehabilitation program;
Plan for educating providers on the provider monitoring process, including review criteria and corrective
actions, initially and ongoing;
Corrective actions to be imposed based on the degree of provider non-compliance with review criteria
elements on both an individual and systemic basis;
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Plan for ensuring corrective actions are implemented appropriately and timely by providers; and
Inter-rater reliability testing methods, including targets, processes to ensure staff participate in reliability
testing reviews initially and at least annually, and processes to ensure staff meet the target rate prior to
conducting reviews independently.
The sample size may be increased at the discretion of LDH.
LDH reserves the right to select the MCO’s sample, require the MCO to modify its provider-monitoring plan
inclusive of monitoring tools, type of monitoring reviews and plans for corrective action.
The MCO shall ensure that an appropriate corrective action is taken when a provider or staff fails to meet
minimum provider qualifications or requirements, appointment availability standards, or is determined to be out
of compliance with provisions of contract requirements, federal and state regulations, law, rules, SPA, waivers, or
Medicaid provider policy manuals. The MCO shall monitor and evaluate corrective actions taken to ensure that
appropriate changes have been made in a timely manner.
The MCO shall submit routine reports using the template provided by LDH which summarize monitoring activities,
findings, corrective actions, and follow-up.
For desktop reviews, the MCO shall maintain documentation used to determine the providers’ compliance for a
minimum of three years from the date of review.
INTEGRATION OF PRIMARY CARE AND BEHAVIORAL
HEALTH SERVICES
In recognizing that at least 70% of behavioral health can be and is treated in the primary care setting, the MCO
shall be responsible for the management and provision of all basic behavioral health services, including, but not
limited to, those with mild or moderate depression, ADHD, and generalized anxiety, that can be appropriately
screened, diagnosed or treated in a primary care setting.
The MCO’s support shall include, but not be limited to, assistance to primary care providers in aligning their
practices with best practice standards, such as those developed by the American Academy of Pediatrics, for the
assessment, diagnosis, and treatment of ADHD, such as increasing the accuracy of ADHD diagnosis, increasing
screening for other behavioral health concerns, and increasing the use of behavioral therapy as first-line treatment
for children under age 6.
SERVICES FOR CO-OCCURRING BEHAVIORAL HEALTH AND
DEVELOPMENTAL DISABILITIES
The MCO shall create a framework for delivery of services, staff development, and policies and procedures for
providing effective care for enrollees with co-occurring developmental disabilities. This population should have
the same reasonable access to behavioral health services as someone without a co-occurring developmental
disability. If an enrollee qualifies for services through the Office for Citizens with Developmental Disabilities
(OCDD), the MCO shall coordinate with Local Governing Entities, Support Coordination Agencies, Office of Public
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Health Title V Children and Special Health Care Needs for those who are under 21, and/or OCDD concerning the
care of the enrollee. A statement of approval from OCDD shall not preclude services from the MCO.
NETWORK DEVELOPMENT AND MANAGEMENT PLAN
The MCO shall submit its comprehensive Network Development and Management Plan in accordance with this
Manual during readiness reviews, as amended, and as requested by LDH.
The MCO shall develop and implement specific strategies to promote the integration of physical and behavioral
health service delivery and care integration activities and establish policies and procedures to facilitate
integration. Specifically, the MCO shall:
Support PCPs who screen enrollees for behavioral health issues and treat mild to moderate cases,
including educating and training practices on how to treat common behavioral health conditions and
providing clinical consultations and guidance for issues that do not require specialty referrals;
Encourage and support providers to co-locate primary care and behavioral health services, whether the
co-located service is in a primary care or behavioral health setting;
The MCO shall provide incentives to clinics to employ Licensed Mental Health Professionals (LMHP) in
primary care settings to monitor the behavioral health of patients and to behavioral health clinics to
employ a primary care provider (physician, physician’s assistant, nurse practitioner, or nurse) part- or full-
time in a psychiatric specialty setting to monitor the physical health of patients;
Allow providers to bill for both primary care and behavioral health services on the same day;
Develop, in coordination with LDH and other MCOs, a system to provide psychiatric prescribing support
to primary care providers. Such support may be provided through consultation with psychiatrists
regarding psychiatric prescribing practices;
The MCO shall endorse real time consultation of primary care providers with behavioral health
professionals or psychiatrists for behavioral health issues or consultations on medications;
Distribute Release of Information forms as per 42 C.F.R. § 431.306, and provide training to providers on
its use;
Share necessary and integrated data with its network providers to promote clinical integration of physical
and behavioral health; and
Offer provider trainings on integrated care, including, but not limited to, appropriate utilization of basic
behavioral health screens in the primary care setting and basic physical health screenings in the behavioral
health setting.
The MCO shall work to integrate physical and behavioral health services through:
Enhanced detection and treatment of behavioral health disorders in primary care settings;
Coordination of care for enrollees with both medical and behavioral health disorders, including promotion
of care transition between inpatient services and outpatient care for enrollees with co-existing medical-
behavioral health disorders;
Assisting enrollees without a diagnosed behavioral health disorder, who would benefit from psychosocial
guidance in adapting to a newly diagnosed chronic medical disorder;
Utilization of approved communication and consultation by PCPs with behavioral health providers of co-
enrolled enrollees with co-existing medical and behavioral health disorders requiring co-management;
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Have enhanced rates or incentives to behavioral health clinics to employ a primary care provider
(physician, physician’s assistant, nurse practitioner, or nurse) part- or full-time in a psychiatric specialty
setting to monitor the physical health of patients;
Have enhanced rates or incentives for integrated care by providers;
Distributing Release of Information forms as per 42 C.F.R. § 431.306, and provide training to MCO
providers on its use;
Educating MCO enrollees and providers regarding appropriate utilization of emergency room (ER)
services, including referral to community behavioral health specialists for behavioral health emergencies,
as appropriate;
Identifying those who use emergency department (ED) services to assist in scheduling follow-up care with
PCP and/or appropriate contracted behavioral health specialists;
Ensuring continuity and coordination of care for enrollees who have been screened positive or determined
as having need of specialized medical health services or who may require inpatient/outpatient medical
health services. These activities must include referral and follow-up for enrollee(s) requiring behavioral
health services;
Documenting authorized referrals in the MCO’s clinical management system;
Providing or arranging for training of MCO providers and Care Managers on identification and screening
of behavioral health conditions and referral procedures;
Conducting Case management rounds at least monthly with the Behavioral Health Case management
team; and
Participating in regular collaborative meetings at least yearly or as needed, with LDH representatives for
the purpose of coordination and communication.
The MCO shall provide guidelines, education and training, and consultation to PCPs to support the provision of
basic behavioral health services in the primary care setting.
The MCO shall ensure network providers utilize behavioral health screening tools and protocols consistent with
industry standards. The MCO shall work to increase screening in primary care using validated screening
instruments for developmental, behavioral, and social-emotional delays, as well as screening for child
maltreatment risk factors, trauma, adverse childhood experiences (ACEs), and substance use. The MCO may
provide technical assistance to providers, incentives, or other means to increase screening for behavioral health
needs in primary care.
The MCO shall work to increase provider utilization of consensus guidelines and pathways for warm handoffs
and/or referrals to behavioral health providers for children who screen positive for developmental, behavioral,
and social delays, as well as child maltreatment risk factors, trauma, adverse childhood experiences (ACEs), and
substance use. The MCO shall work to increase the percentage of children with positive screens who 1) receive a
warm handoff to and/or are referred for more specialized assessment(s) or treatment and 2) receive specialized
assessment or treatment.
For specialized behavioral health services, the MCO shall submit an initial SBHS Network Development and
Management Plan focusing on specialized behavioral health providers using an LDH provided template. This initial
plan shall be submitted as a part of the readiness review. Thereafter, the SBHS Network Development and
Management Plan shall be updated at least annually, or more often as needed to reflect material changes in
network status or as requested by LDH. Subsequent submissions of the SBHS Network Development and
Management Plan shall be submitted utilizing the LDH provided template and include an evaluation of the initial
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Network Development and Management Plan in each subsequent year, inclusive of an evaluation of the success
of proposed interventions, barriers to implementation, and any needed revisions pertaining to the delivery of
specialized behavioral health care.
MATERIAL CHANGE TO PROVIDER NETWORK
The MCO shall submit required information on material changes to its provider network in accordance with this
Manual, the Contract, and in the time period specified by LDH.
The MCO’s request must include a description of any short-term gaps identified as a result of the change and the
alternatives that will be used to fill them, including:
Detailed information identifying the affected provider(s);
Demographic information and number of enrollee currently served and impacted by the event or material
change, including the number of Medicaid enrollees affected by program category;
Location and identification of nearest providers accepting new Medicaid patients offering similar services;
and
For enrollees with special health care needs, a plan for clinical team meetings with the enrollee, his/her
family/caregiver, and other persons requested by the enrollee and/or legal guardian to discuss available
options and revise the service plan to address any changes in services or service providers.
If a provider loss results in a network deficiency, the MCO shall submit to LDH for approval a written plan with
time frames and action steps for correcting the deficiency within 30 calendar days that includes the transitioning
of enrollees to appropriate alternative providers in accordance with the network notification requirements and a
draft notification to impacted enrollees.
The MCO shall track all enrollees transitioned due to a provider or material subcontractor’s suspension, limitation,
termination, or material change to ensure covered service continuity and provide enrollee information as
requested by LDH (e.g., name, Title XIX or Title XXI status, date of birth, services enrollee is receiving or will be
receiving, name of new provider, date of first appointment, and activities to re-engage persons who miss their
first appointment with the new provider).
A material change in the MCO’s provider network requires 30 days advance written notice to affected enrollees.
For emergency situations, LDH may expedite the approval process.
The MCO shall notify LDH within one business day of the MCO becoming aware of any unexpected changes (e.g.,
a provider becoming unable to care for enrollee due to provider illness, a provider death, the provider moves from
the service area and fails to notify the MCO, or when a provider fails credentialing or is displaced as a result of a
natural or man-made disaster) that would impair its provider network. The notification shall include:
Information about how the provider network change will affect the delivery of covered services, and
The MCO’s plan for maintaining the quality of enrollee care, if the provider network change is likely to
affect the delivery of covered services.
The MCO shall give ninety (90) days’ notice prior to a contract termination without cause.
As it pertains to a material change in the network for behavioral health providers, the MCO shall also provide
written notice to LDH, no later than seven business days of any behavioral health network provider contract
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termination that materially impacts the MCO’s provider network, whether terminated by the MCO or the provider,
and such notice shall include the reason(s) for the proposed action. Material changes in addition to those noted
in this section include:
A decrease in a behavioral health provider type by more than 5%;
A loss of any participating behavioral health specialist which may impair or deny the enrollee’s adequate
access to providers; or
A loss of a hospital or residential treatment in an area where another provider of equal service ability is
not available as required by access standards approved by LDH.
PHARMACY NETWORK, ACCESS STANDARDS, AND
REIMBURSEMENT
Pharmacy Claims Dispute Management
The MCO shall maintain an internal claims dispute process to permit local pharmacies to dispute the
reimbursement paid for any claim made for the dispensing of a drug. Reimbursement should be no less than the
FFS rate on the date of service as required by La. R.S. 46:460.36(D). Ingredient cost rates should be updated within
three business days of new rates being posted from the source of choice. The MCO shall be penalized $1,000 per
calendar day for each rate that is not updated within the three business day timeframe.
A local pharmacy is defined as any pharmacy domiciled in at least one Louisiana parish that: contracts directly
with the MCO or the MCO’s contractor in its own name or through a Pharmacy Services Administrative
Organization (PSAO) and not under the authority of a group purchasing organization; and has fewer than ten retail
outlets under the pharmacy’s corporate umbrella.
The MCO shall permit pharmacies to submit claim disputes directly to the MCO or through a PSAO at the
pharmacy's option.
The MCO may require pharmacies to submit claim disputes within a predetermined time limit. Such limit shall be
no less than seven business days after the latter of the fill date or the resolution date of any pending National
Average Drug Acquisition Cost (NADAC) rate update request.
The MCO shall provide written notification of the outcome of the internal claims dispute process to the pharmacy
within seven business days of the date that the dispute was received by the MCO.
Specialty Drugs and Specialty Pharmacies
LDH recognizes the importance of providing adequate access to specialty drugs to Medicaid enrollees while
ensuring proper management of handling and utilization. The MCO shall comply with the specialty drug and
specialty pharmacy requirements specified herein and the Contract.
LDH recognizes the importance of providing adequate access to specialty drugs to Medicaid enrollees while
ensuring proper management of handling and utilization.
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The MCO shall not limit distribution of specialty drugs or self-refer to a MCO or PBM-owned specialty pharmacy.
Any qualified pharmacy that is able to procure specialty drugs from distributors, has any one of the nationally
recognized accreditations and is willing to accept the terms of the MCO’s contract shall be allowed to participate
in the MCO/PBM’s network (any willing provider). LDH reserves the right to deny specialty pharmacy contracts
that include what LDH deems to be overly burdensome terms or requirements, including, but not limited to,
requirements for excessive insurance coverage, unreasonable stocking requirements, or restrictive or duplicative
accreditation requirements. The MCO shall accept any one of the nationally recognized accreditation programs to
meet its specialty pharmacy network requirement.
The MCO specialty pharmacy network shall be approved by LDH prior to MCO reimbursement for specialty drugs.
MCO encounters may be denied until LDH has approved. Any subsequent addition or deletion to the specialty
pharmacy network shall be approved by LDH prior to implementation.
Specialty Drug Criteria
A specialty drug is defined as a prescription drug which meets one the following criteria:
The drug is not routinely dispensed at a majority of retail community pharmacies due to physical or
administrative requirements that limit preparation and/or delivery in the retail community pharmacy
environment. Such drugs may include, but are not limited to, chemotherapy, radiation drugs, intravenous
therapy drugs, biologic prescription drugs approved for use by the federal Food and Drug Administration,
and/or drugs that require physical facilities not typically found in a retail community pharmacy, such as a
ventilation hood for preparation;
The drug is used to treat complex, chronic, or rare medical conditions:
o That can be progressive; or
o That can be debilitating or fatal if left untreated or undertreated; or
o For which there is no known cure.
The drug requires special handling, storage, and/or has distribution and/or inventory limitations;
The drug has a complex dosing regimen or requires specialized administration;
Any drug that is considered to have limited distribution by the federal Food and Drug Administration;
The drug requires:
o Complex and extended patient education or counseling; or
o Intensive monitoring; or
o Clinical oversight; and
o The drug has significant side effects and/or risk profile.
The following categories of drugs shall not be considered specialty drugs:
Any oral medications utilized to treat HIV, Hepatitis B or Hepatitis C;
Any oral medications utilized to treat rheumatoid arthritis, multiple sclerosis or psoriasis (e.g., Aubagio,
Gilenya, Otezla, Xeljanz/Xeljanz XR, etc.);
Any oral medications utilized to treat epilepsy or an immunosuppressant (e.g., Mycophenolate, Sirolimus,
Tacrolimus, etc.);
Self-administered injectable anticoagulants (e.g., Enoxaparin, Fondaparinux, Dalteparin, Unfractionated
heparin, etc.);
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Self-administered injectable human growth hormone (excluding drop-ship items) or self-administered
medications for migraine prophylaxis (e.g., Aimovig, Ajovy, Emgality); and
Self-administered TNF-alpha blockers (e.g., Enbrel, Humira, Simponi, Cimzia), multiple sclerosis agents
(e.g., Copaxone, Interferons, etc.) or psoriatic conditions (e.g., Cosentyx).
Access to Specialty Drugs
No entity shall establish definitions, or require accreditation or licensure, effectively limiting access to prescription
drugs, including specialty drugs, other than the appropriate governmental or regulatory bodies.
Internal Claims Dispute Process
The MCO shall maintain an internal claims dispute process to permit local pharmacies to dispute the
reimbursement paid for any claim made for the dispensing of a drug.
A local pharmacy is defined as any pharmacy domiciled in at least one Louisiana parish that: contracts directly
with the MCO or the MCO’s contractor in its own name or through a Pharmacy Services Administrative
Organization (PSAO) and not under the authority of a group purchasing organization; and has fewer than ten retail
outlets under the pharmacy’s corporate umbrella.
The MCO shall permit pharmacies to submit claim disputes directly to the MCO or through a PSAO at the
pharmacy's option
The MCO may require pharmacies to submit claim disputes within a predetermined time limit. Such limit shall be
no less than seven business days after the latter of the fill date or the resolution date of any pending NADAC rate
update request.
The MCO shall provide written notification of the outcome of the internal claims dispute process to the pharmacy
within seven business days of the date that the dispute was received by the MCO.
No entity shall establish definitions, or require accreditation or licensure, effectively limiting access to prescription
drugs, including specialty drugs, other than the appropriate governmental or regulatory bodies.
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PART 10: PROVIDER SERVICES
The MCO must engage with its network providers to enhance service delivery, improve provider and enrollee
satisfaction, promote data sharing and value-based payment strategies, and enable regular provider participation
in clinical policy development and provider operations. This section provides additional information on ways in
which the MCO interacts and supports its providers to ensure that providers receive timely reimbursement and
appropriate support over the course of the Contract.
PROVIDER DIRECTORY
The MCO shall maintain a complete and accurate provider directory of PCPs, behavioral health providers,
hospitals, specialists, sub-specialists, pharmacies, and ancillary service providers.
See additional requirements in the MCO System Companion Guide.
PROVIDER WEBSITE
The MCO provider website shall include general and up-to-date information about the MCO as it relates to the
Louisiana Medicaid program. This shall include, but is not limited to:
MCO provider manual;
MCO-relevant LDH bulletins;
Limitations on provider marketing;
Information on upcoming provider trainings;
A copy of the provider training manual;
Information on the provider complaint/dispute system;
Information on obtaining prior authorization and referrals;
Enrollee scope of coverage;
Information on how to contact the MCO Provider Relations;
Information on the reporting of fraud, waste, and abuse; and
General up-to-date information about all behavioral health programs and services. This shall include, but
is not limited to, a link to the LDH Behavioral Health Services Provider Manual and any updates for
behavioral health service providers and subcontractors.
PROVIDER HANDBOOK
At a minimum, the provider handbook shall include the following information:
Description of the Medicaid managed care program and the MCO;
A description of all MCO Covered Services outlined in Attachment A, MCO Covered Services, of the
Contract and in the MCO Covered Services section of this Manual;
A description of all behavioral health services;
Enrollee rights and responsibilities (42 C.F.R. 438.100)
Emergency service responsibilities;
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Medical necessity standards as defined by LDH and practice guidelines;
Description of where to obtain service-specific coverage requirements and medical necessity criteria;
Description of how to obtain prior authorization and description of referral procedures, including required
forms;
Enrollee record standards for providers;
Description of where to obtain claims submission protocols and standard including instructions and all
information required for a clean or complete claim;
Protocols for submitting claims data;
Requirements regarding marketing activities and marketing prohibitions;
Requirements regarding background screening for providers;
Requirements regarding the provider enrollment, credentialing and re-credentialing processes;
Policies and procedures that cover the provider complaint system. This information shall include, but not
be limited to: a) specific instructions regarding how to contact the MCO to file a provider complaint,
including complaints about claims issues, and b) the complaint review process, including the timeframes
allowed for resolving claims payment issues, and the process a provider would take to escalate unresolved
issues;
Information about the MCO’s Enrollee Grievance and Appeal System, that with written permission from
the enrollee, the provider may file a grievance or appeal on behalf of the enrollee, the required procedural
steps, time frames and requirements, the availability of assistance in filing, the toll-free telephone
numbers, address and office hours of the grievance staff, the enrollee’s right to request continuation of
services while utilizing the MCO’s grievance and appeal system in accordance with 42 C.F.R. § 438.414,
and any additional information specified in 42 C.F.R. § 438.10(g)(2)(xi);
Practice protocols, including guidelines pertaining to the treatment of chronic and complex conditions;
PCP responsibilities;
Other provider responsibilities under the Contract and as part of the provider’s agreement with the MCO;
Prior authorization and referral procedures;
Standards for record keeping;
Claims submission protocols and standards, including instructions and all information necessary for a
clean and complete claim and samples of clean and complete claims;
MCO prompt pay requirements (see Attachment G, Table of Monetary Penalties);
The MCO’s care management program;
Quality performance requirements;
Provider rights and responsibilities;
Service authorization criteria to make medical necessity determinations;
Information on reporting suspicion of provider or enrollee fraud, waste or abuse; and
Information on obtaining Medicaid transportation services for enrollees.
SPECIALIZED BEHAVIORAL HEALTH PROVIDER TRAINING
REQUIREMENTS
All specialized behavioral health (SBH) services training will be documented with agendas, written training
materials, invited attendees, and sign-in sheets (including documentation of absent attendees). Training to be
provided will include, but not be limited to:
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Cultural competency, including tribal awareness, and health equity for a minimum of three hours per year
and as directed by the needs assessment;
SBH services program requirements, rules, and regulations, including, but not limited to, staff
qualifications and requirements, approved training curricula, approved provider types and specialties,
service definitions, clinical components, service limitations and exclusions, assessment, treatment
planning and medical record requirements, quality management documentation;
Adverse incident management and reporting requirements;
Evidence-based practices, promising practices, emerging best practices;
Billing options and requirements and documentation requirements;
Utilizing the LOCUS assessment tool for specialized behavioral health providers;
Integrating physical and behavioral health;
Assessing and treating individuals with co-occurring I/DD;
Use of MCO systems and website; and
Additional topics as determined through provider/enrollee surveys and/or as directed by LDH.
The MCO’s cultural competency training for SBH providers shall adequately address the criteria included in the
OBH-developed cultural competency best-practice standards. The MCO shall submit cultural competency training
materials to OBH for review and approval, within 30 calendar days of publication of the OBH-developed cultural
competency best-practice standards.
PROVIDER ISSUE RESOLUTION
The MCO shall provide options to providers for pursuing resolution of issues. Providers should first seek resolution
with the MCO directly prior to engaging LDH or other third parties, except when the MCO has demonstrated a
pattern of the same issue reoccurring.
Claim Reconsideration, Appeal, and Arbitration
The MCO shall maintain, in accordance with IB 19-3 or as otherwise approved by LDH, claim dispute procedures
for providers who wish to file formal claim reconsideration requests and claim appeals. Procedures should include
submission instructions and timelines. The MCO shall allow providers 90 calendar days from the date on the
determination letter, from the original request for claim reconsideration, to submit a claim appeal.
In any instance where a provider claim is denied, the consent of the enrollee who received services shall not be
required in order for the provider to dispute the denial of the claim. The provider may pursue a claim dispute on
the basis of nonpayment for rendered services under the terms and conditions outlined in their provider contract
with the MCO or as otherwise provided by Louisiana law. The enrollee who received the services shall not be
required to sign an authorized representative form, or provide other forms of written consent, for the provider to
dispute the denied claim for payment. For each denied claim, providers must be notified of the amount and reason
for the denial.
In any case where a provider is required to obtain a service authorization on a concurrent or post-service basis,
the consent of the enrollee who received the service shall not be required in order for the provider to dispute the
denied authorization for service.
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Providers who have completed the MCO dispute process and remain dissatisfied with the MCO’s determination
may submit a written request for arbitration. The request should include decisions from all claim reconsideration
requests and claim appeals.
Providers may escalate claim disputes to LDH via e-mail at ProviderRelat[email protected]
.
NOTE: Per La. R.S. 46:460.81, an adverse determination involved in litigation or arbitration or not associated with a Medicaid
enrollee shall not be eligible for independent review.
Independent Review
Independent review is another option for resolution of claim disputes. The Independent Review process may be
initiated after claim denial.
NOTE: Per La. R.S. 46:460.81, an adverse determination involved in litigation or arbitration or not associated with a Medicaid
enrollee shall not be eligible for independent review.
The Independent Review process was established by La. R.S. 46:460.81, et seq. to resolve claims disputes
when a provider believes an MCO has partially or totally denied claims incorrectly. An MCO’s failure to
send a provider a remittance advice or other written or electronic notice either partially or totally denying
a claim within 60 days of the MCO’s receipt of the claim is considered a claims denial.
Independent Review is a two-step process which may be initiated by submitting an Independent Review
Reconsideration Request Form to the MCO within 180 calendar days of the Remittance Advice paid,
denial, or recoupment date.
If a provider remains dissatisfied with the outcome of an Independent Review Reconsideration Request,
the provider may submit an Independent Review Request Form to LDH within 60 calendar days of the
MCO’s decision.
There is a $750 fee associated with an independent review request. If the independent reviewer decides
in favor of the provider, the MCO is responsible for paying the fee. Conversely, if the independent reviewer
finds in favor of the MCO, the provider is responsible for paying the fee.
SIU post-payment reviews are not considered claims denials or underpayment disputes, therefore, SIU
findings are exempt from the Independent Review Process.
Additional detailed information and copies of above referenced forms are available on the LDH website
[link
].
Provider Issue Escalation and Resolution
A provider may desire to escalate an issue to the attention of the MCO’s executive team. This may apply to claim
or non-claim related issues.
The MCO is required to maintain a Provider Complaint System for in-network and out-of-network providers to
dispute the MCO’s policies, procedures, or administrative functions. This system should include contacts for filing
a formal complaint and then for escalating to management and executive levels. Providers should first seek
resolution with the MCO, using these contacts. If a provider is unable to reach satisfactory resolution or get a
timely response through the MCO escalation process, direct contact with LDH via ProviderRelations@la.gov
is also
an option.
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If the MCO, LDH, or its subcontractors discover errors made by the MCO when a claim was adjudicated, the MCO
shall make corrections and reprocess the claim within fifteen (15) calendar days of discovery, or if circumstances
exist that prevent the MCO from meeting this time frame, a specified date shall be approved by LDH. The MCO
shall automatically recycle all impacted claims for all providers and shall not require the provider to resubmit the
impacted claims.
ENROLLEE REASSIGNMENT POLICY
Refer to the Primary Care section of Part 9 of this Manual for this policy.
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PART 11: ENROLLEE SERVICES
This section provides information related to services provided by the MCO to its enrollees. Additional information
may be found in the Marketing and Member Education Companion Guide.
AUTHORIZED REPRESENTATIVES OR LEGAL
REPRESENTATIVES
Medicaid enrollees may appoint an authorized representative (AR) to accompany, assist, and represent them in
matters related to their Medicaid coverage. In addition, parents are generally authorized to speak on their minor
child’s behalf regarding the child’s Medicaid without an executed AR form, as long as the parent has been verified
to hold such parental authority. Also, an enrollee may have a legal representative who is designated by operation
of law or by the action of a court. For example, an unemancipated minor child will have someone with parental
authority to act on his or her behalf; usually it will be the parent(s), although in some cases it may be another
person (e.g., legal guardian/curator) or entity who has been appointed by a court (e.g., DCFS when it has legal
custody of a child in foster care).
The case record maintained by LDH is the definitive source of the identity of an enrollee’s AR or legal
representative. The MCO may contact LDH to obtain verification of who is authorized to speak and act on behalf
of the enrollee.
If the MCO needs assistance determining whether a caller is an AR for an enrollee, the MCO should contact the
Medicaid Customer Service Unit (CSU) for a verbal verification. The MCO may conduct the verification through a
three-way call with the AR if preferred. MCOs may call the CSU hotline at 888-342-6207 from 8:00 a.m. to 4:30
p.m. to reach an LDH representative.
The MCO should accept this verification as the source of truth in confirming or denying who is authorized to speak
on behalf of the enrollee. The MCO should not require any additional documents from Medicaid or the enrollee.
In some cases, an MCO may learn of an actual or potential change in an enrollee’s AR or legal representative
before Medicaid does. If that happens, the MCO should be proactive in educating the enrollee/caller to report
changes to Louisiana Medicaid within 10 days and provide direction on contacting Louisiana Medicaid for
assistance.
Nothing in this guidance should be interpreted as creating a barrier to access to treatment for enrollees who are
unable to speak for themselves. If a minor child is brought to a network provider by an adult who does not have
verified parental authority or an AR designation in the child’s record, a reasonable effort should be made to
contact the AR, or the person with verified parental authority over the minor child, to obtain the appropriate
consent for treatment; however, even if that attempt is unsuccessful, it is still legally possible for the provider to
furnish necessary treatment to the child, particularly in emergency situations.
This guidance does not affect the ability of a duly designated AR to sign an authorization permitting the disclosure
of an enrollee’s protected health information to a third person. Medicaid does not seek to dictate the precise
authorization forms to be used by MCOs and their providers, other than to require that they be HIPAA compliant.
Generally, Medicaid will honor any valid, HIPAA compliant authorization that permits it to disclose the requested
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information, but will no longer honor the HIPAA authorization when the person who signed it ceases to be the
enrollee’s AR or is otherwise unauthorized to speak and act on behalf of the enrollee. The MCO should follow the
same policy.
A disclosure authorization of the type discussed in the preceding paragraph is not the same thing as a written
consent for a provider to file a grievance or appeal or to request a state fair hearing on behalf of an enrollee. If an
enrollee, an enrollee’s AR, or an enrollee’s verified legal representative wishes to permit a provider to take such
action on the enrollee’s behalf, a disclosure authorization by itself will not be sufficient for that purpose.
ENROLLEE RIGHTS AND RESPONSIBILITIES
Each enrollee is guaranteed the following rights:
To be treated with respect and with due consideration for his or her dignity and privacy.
To participate in decisions regarding his or her health care, including the right to refuse treatment.
To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or
retaliation, as specified in the federal regulations on the use of restraints and seclusion.
To be able to request and receive a copy of his or her medical records (one copy free of charge) and
request that they be amended or corrected.
To receive healthcare services that are accessible, are comparable in amount, duration and scope to those
provided under Medicaid FFS and are sufficient in amount, duration and scope to reasonably be expected
to achieve the purpose for which the services are furnished.
To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type
of illness, or medical condition. To receive all information (e.g., enrollment notices, informational
materials, instructional materials, available treatment options and alternatives) in a manner and format
that may be easily understood as defined in the Contract between LDH and the MCO.
To receive assistance from both LDH and the enrollment broker in understanding the requirements and
benefits of the MCO.
To receive oral interpretation services free of charge for all non-English languages, not just those identified
as prevalent.
To be notified that oral interpretation is available and how to access those services.
To receive information on the MCO’s services, to include, but not limited to:
o Benefits covered;
o Procedures for obtaining benefits, including any authorization requirements;
o Any cost sharing requirements;
o Service area;
o Names, locations, telephone numbers of and non-English language spoken by current contracted
providers, including at a minimum, primary care dentist, specialists, and hospitals ;
o Any restrictions on enrollee’s freedom of choice among network providers;
o Providers not accepting new patients; and
o Benefits not offered by the MCO but available to enrollees and how to obtain those benefits,
including how transportation is provided.
To receive a complete description of disenrollment rights at least annually.
To receive notice of any significant changes in core benefits and services at least 30 days before the
intended effective date of the change.
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To receive information on grievance, appeal, and state fair hearing procedures.
To receive detailed information on emergency and after-hours coverage, to include, but not be limited to:
o What constitutes an emergency medical condition, emergency services, and post-stabilization
services;
o That emergency services do not require prior authorization;
o The process and procedures for obtaining emergency services;
o The locations of any emergency settings and other locations at which providers and hospitals
furnish emergency services and post-stabilization services covered under the Contract;
o Enrollee’s right to use any hospital or other setting for emergency care; and
o Post-stabilization care services rules as detailed in 42 C.F.R. § 422.113(c).
To receive the MCO’s policy on referrals for specialty care and other benefits not provided by the
enrollee’s PCP.
To have his or her privacy protected in accordance with the privacy requirements in 45 C.F.R. Part 160 and
Part 164, Subparts A and E, to the extent that they are applicable.
To exercise these rights without adversely affecting the way the MCO, its providers or LDH treat the
enrollee.
GRIEVANCES, APPEALS, AND STATE FAIR HEARINGS
Continuation of Benefits
An enrollee is only entitled to a continuation of benefits pending resolution of an appeal or state fair hearing when
a previously authorized benefit is terminated, suspended, or reduced prior to the expiration of the current service
authorization.
Expiration of an approved number of visits does not constitute a termination for purposes of notice and
continuation of benefits. The cessation of services because the authorization expired is not cause for a
continuation of benefits, since the enrollee had no right to expect the services to continue beyond the “previously
authorized” quantity, period, or duration.
When a prescription, including refills, runs out and the enrollee requests another prescription, this is a new
request, not a termination of benefits. In these circumstances, the MCO is not required to send a notice or
continue benefits pending the outcome of an appeal or state fair hearing. If the enrollee requests a reauthorization
that the MCO denied, the MCO shall treat this request as a new request for service authorization and provide
notice of the denial or limitation.
MEDICAL RECORDS
The MCO shall ensure the medical record is:
Accurate and legible;
Safeguarded against loss, destruction, or unauthorized use and is maintained, in an organized fashion, for
all enrollees evaluated or treated, and is accessible for review and audit; and
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Readily available for review and provides medical and other clinical data required for Quality and
Utilization Management review.
The MCO shall ensure the medical record includes, minimally, the following:
Enrollee identifying information, including name, identification number, date of birth, sex and legal
guardianship (if applicable);
Primary language spoken by the enrollee and any translation needs;
Services provided, date of service, service site, and name of service provider;
Medical history, diagnoses, treatment prescribed, therapy prescribed and drugs administered or
dispensed, beginning with, at a minimum, the first enrollee visit with or by the MCO;
Referrals including follow-up and outcome of referrals;
Documentation of emergency and/or after-hours encounters and follow-up;
Signed and dated consent forms (as applicable);
Documentation of immunization status;
Documentation of advance directives, as appropriate;
Documentation of each visit must include;
Date and begin and end times of service;
Chief complaint or purpose of the visit;
Diagnoses or medical impression;
Objective findings;
Patient assessment findings;
Studies ordered and results of those studies;
Medications prescribed;
Health education provided;
Name and credentials of the provider rendering services (e.g. MD, DO, OD) and the signature or initials of
the provider; and
Initials of providers must be identified with correlating signatures.
RETURNED MAIL PROCEDURES
When the MCO receives returned enrollee-related mail, the MCO should first identify whether a forwarding
address has been received.
If a forwarding address is received, the MCO shall:
For out-of-state addresses, follow procedures in place for reporting an enrollee disenrollment request to
the enrollment broker.
For in-state addresses, attempt to contact (including, but not limited to, by phone, mail, e-mail, text) the
enrollee to verify that the newly received address is correct.
If no forwarding address is received, the MCO shall attempt to contact the enrollee as described above.
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PART 12: MARKETING AND EDUCATION
Marketing is defined as communication from an MCO to a Medicaid beneficiary who is not enrolled in that MCO
that can be reasonably be interpreted to influence the beneficiary to: 1) enroll in that MCO, or 2) either not enroll
in, or disenroll from, another MCO.
Member education is communication with an MCO’s enrollee for the purpose of retaining enrollment and
improving the health status of enrollees.
EVENTS AND ACTIVITIES APPROVAL PROCESS
The MCO shall provide advance written notice to LDH for all marketing and member education events and
activities for potential or current enrollees as well as any community/health education activities that are focused
on healthcare benefits (health fairs or other health education and promotion activities). Notice to LDH should be
made in accordance with the Marketing and Member Education Companion Guide.
Any revisions to approved sponsorship, press, or media events and activities must be resubmitted for approval by
LDH prior to the event or activity in accordance with the Marketing and Member Education Companion Guide.
LDH has no jurisdiction to approve or authorize any Health Insurance Exchange activities, including the review of
marketing and member materials. It is the responsibility of the MCO to ensure its Health Insurance Exchange
products are approved by the proper authorities, including the Louisiana Department of Insurance and the U.S.
Department of Health and Human Services. The MCO shall ensure that marketing does not violate any of the terms
and conditions of the Contract.
FOCUS GROUPS
LDH considers any focus group that includes non-enrollee participants to be a marketing effort.
The MCO shall obtain prior written approval from LDH for all focus group concepts. This includes, but is not limited
to, focus group objectives, number of planned participants, cumulative number of non- enrollees who have
participated in previous focus groups during the current contract year and methods for the recruitment of non-
enrollees. Neither the MCO nor its subcontractors may hold a focus group or begin focus group outreach without
written consent of its focus group concept.
LDH will review the submitted focus group concept(s) and either approve, deny or request changes within 30
calendar days from the date of submission.
The MCO must obtain prior written approval from LDH for focus group materials, as it does for all marketing and
member materials. Focus group materials include, but are not limited to, scripts and other materials used in the
focus group. In the case of focus group materials, the layout or presentation must be approved as well as the text.
LDH will review the submitted focus group materials, and either approve, deny or request changes within 30
calendar days from the date of submission.
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The MCO must obtain prior written approval from LDH for any focus group event. A focus group event is defined
as an event where enrollees and/or potential enrollees are brought together in order to be questioned about
their opinions about health insurance, Medicaid, MCOs, Medicaid Managed Care, or any related subject. The
proposed focus group event should be submitted to LDH in accordance with the Marketing and Member Education
Companion Guide. Required data elements include, but are not limited to, Event Date, Event Start Time, Event
End Time, Street Address and City. Information as to whether or not inconspicuous observation is possible at the
chosen venue should be included in the “Comments” field.
Focus group events should not be submitted for LDH review until all materials for that focus group concept have
been approved.
LDH will review proposed focus group events and either approve or deny within 14 calendar days from the date
of submission.
The MCO must limit total non-member participation to 50 individuals in any one contract year.
There is no limit placed on enrollee participation in focus groups.
The maximum incentive that may be offered to each individual non- enrollee participant of a focus group is $100
in an urban area (East Baton Rouge, Jefferson, Orleans and St. Bernard parishes) or $125 in a rural area (parishes
not specifically listed above).
The MCO shall provide LDH or its representatives access to any focus group event, where inconspicuous
observation is possible, upon request.
Data and its analysis resulting from all focus group events must be submitted to LDH for informational purposes
upon request.
REPORTING
Marketing and Member Education Plan
The MCO shall develop and implement a Marketing and Member Education Plan in accordance with the Marketing
and Member Education Companion Guide. The detailed plan must be submitted to LDH for approval as part of
the readiness review or within 30 days of Contract execution, before a new goal or strategy is implemented, and
annually thereafter within 30 calendar days of the end of the calendar year, if another plan has not been submitted
within the last six months.
The MCO shall not conduct member education activities associated with the Contract prior to approval of the
plan.
The plan shall take into consideration projected enrollment levels for equitable coverage of the entire MCO service
area. The plan should clearly distinguish between marketing activities and materials and member education
activities and materials.
The MCO shall submit any changes to the Marketing and Member Education Plan or included materials or activities
to LDH for approval at least 30 days before implementation of the material or activity, unless the MCO can
demonstrate just cause for an abbreviated timeframe.
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Marketing and Member Education Report
The MCO shall submit a quarterly Marketing and Member Education Report in accordance with the Marketing
and Member Education Companion Guide. The report shall include all events in which the MCO has participated
during the reporting quarter. It shall also include a listing of all marketing and member education materials
distributed by the MCO during the reporting period.
Alleged Marketing Violations
Alleged marketing violations shall be reported to LDH in writing utilizing the Marketing Complaint Form.
MCO BRAND AND LOGO
The MCO shall clearly distinguish between its Medicaid and commercial products in its branding and logo usage
to ensure federal requirements against direct marketing to Medicaid enrollees are not compromised.
STEERING
Patient steering is defined in Title 50 of the Louisiana Administrative Code as unsolicited advice or mass-marketing
directed at Medicaid beneficiaries by MCOs, including any of the entity’s employees, affiliated providers, agents,
or contractors, that is intended to influence or can reasonably be concluded to influence the Medicaid beneficiary
to enroll in, not enroll in, or disenroll from a particular MCO.
If the MCO or its providers are found to have engaged in patient steering, they may be subject to non-compliance
actions including, but not limited to, monetary penalties, loss of linked patients, and exclusion from enrollment in
Medicaid/Medicaid managed care network opportunities.
The MCO should ensure that its network providers adhere to the following:
Providers may inform their patients of all MCO networks in which they participate, and may inform
patients of the benefits, services, and specialty care services offered through the MCOs in which they
participate.
Providers are not allowed to disclose only some of the MCOs in which they participate. Disclosure of MCO
participation must be all or nothing.
Providers may display signage, provided by the MCO, at their locations indicating which MCOs are
accepted there, but must include all MCOs in which they participate in this signage.
Providers may not recommend one MCO over another MCO and may not offer patients incentives for
selecting one MCO over another. Providers may allow use of office equipment (e.g., phones, computers,
etc.) for enrollee-directed enrollment or disenrollment purposes.
Patients who need assistance with their MCO services should call the member call center for the MCO in
which they are enrolled, and those who wish to learn more about the different MCOs should contact the
enrollment broker at 1-855-229-6848 to receive assistance in making an MCO decision.
Under no circumstances is a provider allowed to change an enrollee’s MCO or request an MCO
reassignment on an enrollee’s behalf. Disenrollment requests must be initiated and approved by the
enrollee.
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These prohibitions against patient steering apply to participation in the Medicaid managed care and the legacy
Medicaid programs.
For pharmacies enrolled as Louisiana Medicaid providers, or contracted with any MCO’s pharmacy benefit
manager, the same steering prohibitions stated above apply to communications with Medicaid/Medicaid
managed care patients.
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PART 13: QUALITY
LDH’s Medicaid Managed Care Quality Strategy (“Quality Strategy”) defines and drives the overall vision for
advancing health outcomes and quality of care provided to Louisiana Medicaid enrollees. The MCO must have an
overall quality management and quality improvement approach with specific strategies that advance the Quality
Strategy and LDH’s incentive-based quality measures.
LDH has also developed an MCO Quality Companion Guide that focuses on core quality improvement activities.
The MCO shall refer to this companion guide for clarification of contract requirements and external quality review
organization (EQRO) activities and processes. This includes timeline and format specifications for performance
measure and Performance Improvement Project (PIP) reporting.
LDH has established the opportunity for MCOs to participate in incentive arrangements in accordance with 42
C.F.R. § 438.6(b). Each incentive arrangement will include specified activities, targets, performance measures, or
quality-based outcomes for a fixed length of time that support the Quality Strategy. These incentive arrangements
will collectively be known as the Managed Care Incentive Payment (MCIP) program. All incentive arrangements
must comply with the MCIP Program Protocol developed by LDH and the MCIP section of the Contract.
See the Resources section for links to the Quality Strategy and MCO Quality Companion Guide.
PERFORMANCE IMPROVEMENT PROJECTS
At LDH’s request, prior to initiation for each LDH-directed PIP, the MCO shall submit in writing a PIP proposal, in
compliance with this Manual and the Contract, for LDH approval. The Proposal shall include:
An overview explaining how and why the project was selected, the status of the PIP, and its relevance to
the MCO enrollees and providers;
The study question;
The study population;
The quantifiable measures to be used, including the baseline and goal for improvement;
Baseline methodology;
Data sources;
Data collection methodology and plan;
Data collection plan and cycle, which must be at least monthly;
Results with quantifiable measures;
Analysis with time period and the measures covered;
Explanation of the methods to identify opportunities for improvement; and
An explanation of the initial interventions to be taken.
For behavioral health, the MCO shall develop and implement a mechanism for soliciting feedback from in-
network providers and facilities to identify barriers/issues and inform intervention, if recommended by LDH.
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Performance Improvement Projects Reporting Requirements
The MCO shall submit to LDH project data analysis quarterly or as determined by LDH.
The MCO shall submit project outcomes annually to LDH.
Reporting specifications are detailed in the MCO Quality Companion Guide.
LDH reserves the right to request additional reports as deemed necessary. LDH will notify the MCO of additional
required reports no less than 30 days prior to due date of those reports.
PIPs used to measure performance improvement shall include diagrams (e.g. algorithms and/or flow charts) for
monitoring and shall:
Target specific conditions and specific health service delivery issues for focused system-wide and
individual practitioner monitoring and evaluation;
Use clinical care standards and/or practice guidelines to objectively evaluate the care the MCO delivers
or fails to deliver for the targeted clinical conditions;
Use appropriate quality indicators derived from the clinical care standards and/or practice guidelines to
screen and monitor care and services delivered;
Implement system interventions to achieve improvement in quality, including a (PDSA) cycle;
Evaluate the effectiveness of the interventions;
Provide sufficient information to plan and initiate activities for increasing or sustaining improvement;
Monitor the quality and appropriateness of care furnished to enrollees with special health care needs;
Reflect the population served in terms of age groups, disease categories, and special risk status,
Ensure that multi-disciplinary teams will address system issues;
Include objectives and quantifiable measures based on current scientific knowledge and clinical
experience and have an established goal benchmark;
Validate the design to ensure that the data to be abstracted during the QI project is accurate, reliable and
developed according to generally accepted principles of scientific research and statistical analysis, and
Maintain a system for tracking issues over time to ensure that actions for improvement are effective.
ENROLLEE ADVISORY COUNCIL
The Council is to be chaired by the MCO’s Administrator/CEO/COO or designee and will meet at least quarterly.
Every effort shall be made to include statewide broad representation of both enrollees/families/significant others,
enrollee advocacy groups and providers that reflect the population and community served. At least one family
member/caregiver of a child with special health care needs shall have representation on the committee.
Enrollees/families/significant others and enrollee advocacy groups shall make up at least 50% of the membership.
The MCO shall provide an orientation and ongoing training for Council members so they have sufficient
information and understanding to fulfill their responsibilities.
The MCO shall develop and implement an Enrollee Advisory Council Plan that outlines the schedule of meetings
and the draft goals for the council that includes, but is not limited to, enrollees’ perspectives to improve quality
of care. This plan shall be submitted to LDH during the readiness review and annually thereafter.
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LDH shall be included in all correspondence to the Council, including the distribution of council meeting agendas
and minutes. Additionally, all council meeting agendas and minutes shall be posted to the MCO website in English
and Spanish, with any enrollee-identifying information redacted. Council meeting minutes shall be submitted to
within 30 calendar days after the council meeting and posted to the MCO website within
thirty (30) calendar days after LDH approval.
ADVERSE INCIDENT AND QUALITY OF CARE CONCERNS
MANAGEMENT AND REPORTING
The MCO shall assess, investigate, report, and follow-up on all adverse incidents involving the specialized
behavioral health population, including:
Assuring the enrollee is protected from further harm and that medical or other services are provided, as
needed;
Following up to determine cause and details of the critical incident if a provider agency or staff is involved;
Identifying possible measures to prevent or mitigate the reoccurrence of similar critical incidents; and
Monitoring the effectiveness of remedial actions when a provider agency or staff is involved.
The MCO shall assure providers complete and submit adverse incident reports within one business day of
discovery of the incident.
If appropriate, the MCO and providers must report allegations of abuse, neglect, exploitation, or extortion directly
and immediately to the appropriate protective services agency or licensing agency. The following agencies are
responsible for investigating such allegations:
Department of Child and Family Service (DCFS);
Adult Protective Services (APS) for vulnerable individuals ages 18 to 59;
Governor’s Office of Elderly Affairs Elderly Protective Services (EPS) for vulnerable individuals ages 59 and
over; and
LDH Health Standards Section (HSS) for people who reside in a public or private Intermediate Care Facility,
persons with Developmental Disabilities (ICF/DD), ICF/Nursing Facilities, and CPS or APS cases in which
the alleged perpetrator is an employee of an agency licensed by HSS.
Community providers are prohibited from using restrictive interventions/restraints. Any instances of restraint that
threaten enrollees’ health and welfare should be reported and referred to the appropriate protective service
agency and the Health Standards Section.
The following are types of adverse incidents:
Abuse (child/youth) - any one of the following acts that seriously endanger the physical, mental, or
emotional health and safety of the child.
o The infliction, attempted infliction, or, because of inadequate supervision, the allowance of the
infliction or attempted infliction of physical or mental injury upon the child by a parent or any
other person.
o The exploitation or overwork of a child by a parent or any other person.
o The involvement of a child in any sexual act with a parent or any other person.
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o The aiding or toleration by the parent of the caretaker of the child’s sexual involvement with any
other person or of the child’s involvement in pornographic displays or any other involvement of
a child in sexual activity constituting a crime under the laws of this state. (La. Ch. Code art. 603(2))
Abuse (adult) - the infliction of physical or mental injury, or actions which may reasonably be expected to
inflict physical injury, on an adult by other parties, including but not limited to such means as sexual abuse,
abandonment, isolation, exploitation, or extortion of funds or other things of value. (La. R.S. 15:1503(2))
Death - regardless of cause or the location where the death occurred. Documentation must address dates
of all events and correspondence; cause of death; if the enrollee was receiving hospice or home health
services; the who, what, when, where and why facts concerning the death; and relevant medical history
and critical incidents associated with the death.
Exploitation (adult) - the illegal or improper use or management of the funds, assets, or property of a
person who is aged or an adult with a disability, or the use of power of attorney or guardianship of a
person who is aged or an adult with a disability for one's own profit or advantage. (La. R.S. 15:1503(7))
Extortion (adult) - the acquisition of a thing of value from an unwilling or reluctant adult by physical force,
intimidation, or Abuse of legal or official authority. (La. R.S. 15:503(8))
Neglect (child/youth) - the refusal or unreasonable failure of a parent of caretaker to supply the child with
the necessary food, clothing, shelter, care, treatment, of counseling for any illness, injury, or condition of
the child, as a result of which the child’s physical, mental or emotional health and safety are substantially
threatened or impaired. This includes prenatal illegal drug exposure caused by the parent, resulting in the
Newborn being affected by the drug exposure and withdrawal symptoms. (La. Ch. Code art. 603(18))
Neglect (adult) - the failure, by a caregiver responsible for an adult's care or by other parties, to provide
the proper or necessary support or medical, surgical, or any other care necessary for his well-being. No
adult who is being provided treatment in accordance with a recognized religious method of healing in lieu
of medical treatment shall for that reason alone be considered to be neglected or abused. (La. R.S.
15:1503(10))
OUTCOME ASSESSMENT FOR BEHAVIORAL HEALTH
SERVICES
Reserved.
QUALITY MONITORING REVIEWS FOR BEHAVIORAL HEALTH
PROVIDERS
The MCOs shall collaborate with each other to develop and implement a plan for monitoring specialized
behavioral health (SBH) providers and facilities across all levels of care, which incorporates onsite reviews and
enrollee interviews, with a focus on unlicensed providers delivering care. . In addition, the plan shall also specify
the methods that will be employed by the MCO to monitor hospitals’ development of discharge plans with
aftercare appointments in collaboration with members for BH-related discharges. The MCO shall conduct quality
monitoring reviews on a sample of providers on a quarterly basis. The MCO shall submit the plan to LDH for
approval within 60 calendar days after the operational start date and at least 60 calendar days prior to material
change. The MCO’s plan shall comply with all the requirements as specified by LDH:
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Review criteria for each applicable service which evaluates if the assessment and treatment are conducted
timely and include enrollee participation, the quality of the assessment and treatment plan, whether
enrollees are receiving services as reflected in the treatment/service plan, clinical practice guideline
adherence, patient safety including adverse incident management/reporting, care coordination,
discharge planning as applicable, enrollee rights and confidentiality;
Plan for updating review criteria based on changes to requirements as reflected in the applicable provider
manual or rule;
Number of charts to be reviewed at each provider location (the MCO shall review a reasonable number
of records to determine each provider’s compliance rate) and look-back period;
Enrollee interview criteria, including target number of enrollees to be interviewed and survey questions,
to evaluate quality of care, satisfaction, receipt of service, and enrollee outcomes;
Onsite review criteria;
Sample selection criteria, including inclusion and exclusion criteria, and representative sample size;
Tools to be used and weight of each review element;
Qualifications for staff performing monitoring reviews who at a minimum must be an LMHP or psychiatrist
unless otherwise approved by LDH;
Plan for educating providers on the provider monitoring process, including review criteria and corrective
actions, initially and ongoing;
Corrective actions to be imposed based on the degree of provider non-compliance with review criteria
elements on both an individual and systemic basis;
Plan for ensuring corrective actions are implemented appropriately and timely by providers; and
Inter-rater reliability testing methods, including targets, processes to ensure staff participate in reliability
testing reviews initially and at least annually, and processes to ensure staff meet the target rate prior to
conducting reviews independently.
The sample size may be increased at the discretion of LDH. LDH reserves the right to select the MCO’s sample.
The MCO shall ensure that an appropriate corrective action is taken when a provider furnishes inappropriate or
substandard services, when a provider does not furnish a service that should have been furnished, or when a
provider is out of compliance with federal and state requirements. The MCO shall monitor and evaluate corrective
actions taken to ensure that appropriate changes have been made in a timely manner.
The MCO shall submit routine reports using the template provided by LDH which summarize monitoring activities,
findings, corrective actions, and improvements for SBH services.
For desktop reviews, the MCO shall maintain documentation used to determine the providers’ compliance for a
minimum of three years from the date of review.
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PART 14: VALUE-BASED PAYMENT
Value-based payment (VBP) is a broad set of performance-based payment strategies that link financial incentives
to providers’ performance on a set of defined measures of quality and/or cost or resource use.
VBP STRATEGIC PLAN
The MCO shall develop its VBP Strategic Plan in accordance with Attachment E, APM Strategic Plan Requirements
and Reporting Template.
MINIMUM VBP THRESHOLD AND QUALIFYING VBP
ARRANGEMENTS
The MCO shall demonstrate that it has met the minimum VBP threshold established as defined by LDH in
accordance with the Contract and Attachment E, APM Strategic Plan Requirements and Reporting Template.
PHYSICIAN INCENTIVE PLAN
The MCO’s Physician Incentive Plans shall be in compliance with 42 C.F.R. § 438. 3(i), § 422.208 and § 422.210, the
Contract, and the Physician Incentive Plan Requirements in the Resources section.
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PART 15: PROGRAM INTEGRITY
Preventing and detecting Medicaid fraud, waste, and abuse requires a collaborative effort by various parties.
LDH, the Louisiana Legislative Auditor's Office, and the Office of the Attorney General are responsible for
identifying and reviewing suspected incidents of fraud, waste, and abuse. This includes the preliminary
investigation of credible allegations of fraud, the preliminary and full investigation of fraud, waste, and/or abuse,
and any other matters necessary to comply with federal and state regulations. The Office of the Attorney General
conducts criminal investigation and prosecution of fraud and abuse by providers, via its Medicaid Fraud Control
Unit (MFCU), and by enrollees based on LDH and MCO referrals and complaints received from the public.
The MCO is responsible for quality review, compliance, and fraud and abuse investigation. Subjects may be MCO
employees, subcontractors, providers, and enrollees. The MCO has no criminal review authority, although it may
pursue civil damages, so the MCO is required to report suspected and confirmed fraud and abuse to LDH and
MFCU. A summary of responsibilities is provided below.
INVESTIGATIONS
All reviews shall be completed within 10 months (300 calendar days) unless an extension is authorized. Requests
for extensions to investigations are to be e-mailed to LDH as needed.
REFERRALS/NOTICES
All provider and enrollee fraud and abuse must be reported to the appropriate agencies as follows:
Type
Reported To
Reporting Template
Provider (confirmed)
LDH and MCFU
MCO Fraud Referral Template
Provider (suspected)
LDH and MCFU
MCO Fraud Notice Template
Enrollee (confirmed or suspected)
LDH and local law enforcement
MCO Member Fraud Referral Template
LDH and MFCU screen all referrals for potential payment suspension. MFCU may choose to open its own
investigation, or it may use the information to expand an existing investigation. For this reason, the MCO must
refrain from contacting the subject of the fraud referral until LDH confirms the MCO may continue its review.
There is no such prohibition on contacting the subject of a fraud notice.
REPORTING
The MCO must report all audits, overpayments identified, and recoveries by the MCO and its subcontractors,
including subcontractors that pay claims (e.g., PBMs, transportation brokers), using the LDH reporting template.
The MCO must adjust encounters when it discovers the data is incorrect or no longer valid or that some element
of the claim needs to be changed.
When overpayments associated with fraud, waste, and abuse are identified, the MCO shall start the process of
voiding or adjusting claims and encounters within 14 days of being considered final, regardless of recovery status.
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Overpayments are considered final when all appeals and grievances have been exhausted. All voids should be
completed within 45 calendar days of the overpayment being considered final. A 45 calendar day extension will
be allowed for those overpayments involving 500 or more claim lines.
TIPS
All tips regarding any potential billing or claims issue identified through complaints or internal review shall be
reported to LDH by the 20
th
of the month.
The MCO shall promptly perform a preliminary investigation of all incidents of suspected and/or confirmed fraud
and abuse, including tips shared with the MCO by LDH in the monthly tips reports.
FWA COMPLIANCE PROGRAM
The MCO is required to implement and maintain arrangements to detect and prevent fraud, waste, and abuse.
The FWA Compliance Plan is due to LDH annually and prior to changes.
LDH Program Integrity may initiate reviews of the MCO’s FWA detection and prevention activities.
PROGRAM INTEGRITY MEETINGS
LDH Program Integrity hosts regular meetings to discuss fraud, abuse, waste, neglect, and overpayment issues
with the MCOs and the state’s Office of Attorney General MFCU, which the MCO Program Integrity Officer and
CEO or COO are required to attend. The MCO’s SIU investigators are encouraged to participate.
EXCLUSIONS & PROHIBITED AFFILIATIONS
The MCO may not employ or contract with an individual or entity that is debarred, suspended, or excluded from
participating in any federal health care program, or with any individual or entity that is an affiliate of such an
individual or entity. This includes:
Any person with an ownership or control interest; and
MCO staff, MCO owners, subcontractors, and network providers.
The list of entities excluded from federally funded health care programs can be found at the U.S. Department of
Health and Human Services website [link], the System for Award Management [link
], Louisiana Adverse Actions
List [link], and the Health Integrity and Protection Data Bank [link].
The MCO must conduct all required exclusion screenings monthly. The Exclusion Database Attestation is due to
LDH by the 15
th
of every month. The attestation confirms that the monthly screening of providers, employees and
subcontractors has been completed as required in the contract and 42 C.F.R. § 455.436.
In the event payments were paid to an excluded provider, LDH may recover those funds directly from the MCO
via deduction from their capitation payment. Upon identification by the state, the MCO will be given 30 days to
respond and/or provide documentation that disputes the findings.
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SAMPLING OF PAID CLAIMS
On a monthly basis, the MCO must provide individual explanation of benefits (EOB) notices to a sample group of
enrollees to verify that services were received by the enrollees as billed.
The MCO shall track and investigate any complaints received from enrollees that the billed services were not
rendered as stated.
The sampling of paid claims report is due 30 days after the end of the calendar year quarter.
OVERPAYMENTS
MCOs may recover any overpayments identified by the MCO; however, the MCO must confer with LDH before
initiating recoupment or withhold on providers previously identified through audit coordination to ensure that
the recovery is permissible, meaning the funds are not already set for recovery under an open LDH or MFCU
review.
Unless prior approval is obtained from LDH, the MCO must not employ extrapolation methods to derive an
overpayment in a provider audit. LDH follows published CMS guidelines used by Medicare recovery contractors
to determine whether an extrapolation is permissible.
PREPAYMENT REVIEW
La. R.S. 46:460.76, as enacted by Act No. 534 of the 2022 Regular Session, prohibits MCOs from requiring any
enrolled provider to be subject to prepayment review unless the requirement is implemented by LDH and in
accordance with the provisions of the Medical Assistance Programs Integrity Law, La. R.S. 46:437.1 et seq.
The MCO’s policy for prepayment review shall include the following:
If the MCO identifies a provider they believe should be placed on prepayment review, the MCO shall
complete a Prepayment Review Request Form and e-mail the completed form, along with any relevant
supporting documentation, to PrepaymentReviewRequ[email protected]
.
The LDH MCO Oversight unit will follow LAC 50:I.5.Chapter 41, otherwise known as the “SURS Rule”, when
reviewing prepayment review requests.
LDH will notify the MCO via e-mail of the decision on a prepayment review request. If the request is
approved, the MCO may place the provider on prepayment review effective the date of receipt of
approval.
Prepayment review is not a sanction and cannot be appealed, nor is it subject to an informal hearing.
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AUDIT COORDINATION
Surveillance and Utilization Review Audit Coordination
Preliminary Review of Data
LDH Program Integrity (PI) in conjunction with Surveillance and Utilization Review (SURS) reviews
encounter data of all of the MCOs on a regular basis.
If a potential overpayment is identified for a provider within the MCO’s network, SURS will send a secure
e-mail to the MCO for vetting.
Contact with the MCOs
The e-mail to the MCOs will contain information pertaining to the potential overpayment. The following
information may be sent depending on the information available:
o A description of the issue(s) and provider information.
o An attachment with the encounter data and the preliminary results of each encounter audited.
o A copy of the draft letter containing each area of review.
The MCO is given a deadline to indicate whether the encounter data has been or is in the process of being
corrected, adjusted, or audited.
Audit Clearance
If the issues or data anomalies relating to the providers were audited or are in the process of being audited
by the MCO, SURS will need a copy of the results in order for the SURS case to be closed with “no action”.
If the providers were not previously audited by the MCOs, SURS will proceed with the audits (i.e.,
contacting the providers, requesting records, sending recoupment letters, etc.).
Audit
Records will be requested for the SURS analyst and/or consultants to review or encounters will be given
for the provider to do a self-audit.
All letters have contact information of the SURS analyst who is performing the audit if additional
information or clarification is needed.
If an overpayment is identified, a recoupment letter containing each area of review and the encounter-
level detail will be sent.
Conclusion of the Audit
The provider has informal and appeal rights (refer to the SURS Rule and the Medical Assistance Program
Integrity Law (MAPIL) for detailed information).
If a recoupment is identified, SURS will collect the amount owed from the MCO via a deduction from the
MCO’s capitation payment. The MCO may pursue recovery from the provider as a result of the State-
identified overpayment.
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The MCO will receive an e-mail notification from the SURS analyst that the review is complete and provide
the timing of the capitation deduction.
Unified Program Integrity Contractor Audit Coordination
Preliminary Review of Data
Program Integrity (PI) in conjunction with the Unified Program Integrity Contractor (UPIC) reviews
encounter data of all of the MCOs on a regular basis.
If a potential overpayment is identified for a provider within the MCO’s network, PI will send a secure e-
mail to the MCO for vetting.
Contact with the MCOs
The e-mail to the MCO will contain information pertaining to the type/scope of the audit.
The MCO is given a deadline to indicate whether the encounter data has been or is in the process of being
corrected, adjusted or audited.
Audit Clearance
If the issues or data anomalies relating to the providers were audited or is in the process of being audited
by the MCO, those MCO claims are removed from the potential universe of claims for the UPIC case.
If the providers were not previously audited by the MCOs, UPIC will proceed with the audit (request
records, question providers/recipients, produce a final report, etc.).
Audit
Records will be requested for UPIC to review.
If an overpayment is identified, UPIC will produce a final report to the PI Unit. PI will draft/mail all
correspondence to the provider, and enclose the final report.
Conclusion of the Audit
The provider has informal and appeal rights. Refer to the SURS Rule and the Medical Assistance Program
Integrity Law (MAPIL) for detailed information.
If a recoupment is identified, PI will collect the amount owed from the MCO via a deduction from the
MCO’s capitation payment. The MCO may pursue recovery from the provider as a result of the State-
identified overpayment.
The MCO will receive an e-mail notification from the UPIC analyst that the review is complete and provide
the timing of the capitation deduction.
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PART 16: PAYMENT & FINANCIAL PROVISIONS
CAPITATED PAYMENTS
Capitated payments (also referred to as “PMPM payments”) are the fixed payments that LDH makes to the MCO
for each enrollee covered under the Contract for provision of MCO covered services. This payment is made
regardless of whether the enrollee receives any MCO covered services during the period covered by the payment.
KICK PAYMENTS
Kick payments are one-time fixed payments, in addition to the capitated payment, that LDH reimburses the MCO
for specific services.
For each obstetrical delivery, LDH reimburses a maternity kick payment to cover the cost of prenatal care, the
delivery event, and post-partum care and uncomplicated newborn hospital costs. Kick payments may be
differentiated between early elective delivery events and all other delivery events.
MCO PAYMENT SCHEDULE
The MCO should refer to the payment schedule established by LDH and published on www.lamedicaid.com.
FINANCIAL INCENTIVES FOR MCO PERFORMANCE
LDH withholds 2% of the MCO’s monthly capitated payments to incentivize quality, health outcomes, and value-
based payments.
The MCO may earn back the Quality Withhold for the measurement year based on its performance relative to
incentive-based measures and targets as established by LDH and specified in the Contract, prior to the start of the
measurement year.
The MCO may earn back the VBP Withhold based on its reporting and performance relative to VBP requirements
and targets as established by the Contract. The MCO shall report on its VBP use as directed by LDH.
MEDICAL LOSS RATIO
In accordance with the Financial Reporting Guide, the MCO shall provide an annual Medical Loss Ratio (MLR)
report following the end of the MLR reporting year.
RISK SHARING
The Medicaid managed care program is a full risk-bearing, MCO healthcare delivery system responsible for
providing specified Medicaid covered services included in the Louisiana Medicaid State Plan to Medicaid enrollees.
MCO Manual | PAYMENT & FINANCIAL PROVISIONS 251
An MCO assumes full risk for the cost of covered services under the Contract and incurs loss if the cost of furnishing
these covered services exceeds the payment received for providing these services.
Risk mitigation strategies established under the Contract include the following:
Risk corridor for Hepatitis C-related pharmacy, physician, and laboratory costs; and
Risk pools for high cost, low utilization drugs.
Additional information about the risk corridors may be found in the Contract and the Financial Reporting Guide.
DETERMINATION OF MCO RATES
LDH shall establish actuarially sound capitation rates for enrollees assigned to the MCO to ensure that MCO
covered services under the Contract are provided. Rates are set using available and appropriate sources, including
FFS claims data, encounter data, and financial data and supplemental ad hoc data and analyses, and adjusted
based on factors such as utilization trend, unit cost trend, TPL recoveries, and administrative costs.
RISK ADJUSTMENT
Capitated payments are risk adjusted, as deemed appropriate by LDH, to account for variation in health risks
among participating MCOs.
RETURN OF FUNDS
LDH may deduct from the monthly capitation payment amounts owed by the MCO to LDH. LDH will provide
written instruction to the MCO if funds are to be returned in any other manner.
COST SHARING
In accordance with 42 C.F.R. § 447.56(f)(1), Medicaid cost sharing incurred by all individuals in a Medicaid
household may not exceed an aggregate limit of 5% of the family’s income applied on a monthly basis as directed
by LDH. The MCO/Pharmacy Benefit Manager will implement a Point of Sale edit that will apply a per-enrollee
maximum monthly copayment and turn off cost sharing when maximum copayments are met. LDH’s fiscal
intermediary will send the MCO a file with the per-enrollee maximum monthly copayment.
The MCO and its subcontractors also may not impose copayments for the following:
Family planning services and supplies;
Emergency services;
U.S. Preventive Services Task Force (USPSTF) A and B Recommendations; and
Services provided to:
o Individuals younger than 21 years old;
o Pregnant women;
o Individuals who are inpatients in long-term care facilities or other institutions;
o Native Americans;
o Alaskan Eskimos;
MCO Manual | PAYMENT & FINANCIAL PROVISIONS 252
o Enrollees of an Home and Community Based Waiver;
o Women whose basis of Medicaid eligibility is Breast or Cervical Cancer; and
o Enrollees receiving hospice services.
MCO Manual | THIRD PARTY LIABILITY 253
PART 17: THIRD PARTY LIABILITY
Pursuant to federal and state law, the Medicaid program is intended to be the payer of last resort. This means all
other available third party liability (TPL) resources must meet their legal obligation to pay claims before the MCO
pays for the care of an individual eligible for Medicaid.
The following third parties must be billed prior to billing Medicaid. This list is not exhaustive.
Health insurance:
o Policies and indemnity policies that make payment when a medical service is provided and that
restrict payment to the period of hospital confinement.
o Policies that pay income supplements for lost income due to disability or policies that make a
payment for a disability, such as weekly disability policy, are not included;
Major medical, drug, visions care and other supplements to basic health insurance contracts;
TRICARE-provides coverage for off base medical services to dependents of uniformed service personnel,
active or retired;
Veteran Administration (CHAMP-VA) provides coverage for medical services to dependents of living and
deceased disabled veterans;
Railroad Retirement;
Automobile medical insurance;
Worker’s compensation;
Liability insurance-includes automobile insurance and other public liability policies, such as home accident
insurance, etc.; and
Family health insurance carried by an absent parent.
When an enrollee has other insurance, the enrollee must follow any and all requirements of that insurance since
it is primary. If the enrollee does not follow private insurance rules and regulations, the MCO will not be
responsible for considering reimbursement of those services. Thus, the enrollee will be responsible for the
payment of the services.
Providers must determine, prior to providing services, to which commercial plan the enrollee belongs and if the
provider of service is a part of the network of that particular plan. Enrollees must be informed prior to the service
that they will be responsible for payment if they choose to obtain services from an out-of-network provider and
their commercial plan does not offer out-of-network benefits.
When an enrollee has other insurance, with the exception of specialized behavioral health services, the provider
shall first seek authorization from the primary payer; if authorized by the primary payer, the provider shall bill the
MCO as secondary payer. If not authorized by the primary payer, the provider may seek authorization from the
MCO for evaluation of medical necessity.
The MCO shall process these claims as they were processed by the primary payer. The payment information
indicated on the primary payer’s EOB will be used to process the claim. Additionally, Medicaid TPL payments will
be calculated differently for enrollees enrolled through the Louisiana Health Insurance Premium Payment
Program (LaHIPP). Refer to the LaHIPP section for LaHIPP TPL calculation.
Specific payment mechanisms surrounding the TPL populations shall be determined by LDH in accordance with
the MCO System Companion Guide.
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COST AVOIDANCE
Except for “pay and chase” claims identified in this section, the MCO shall cost-avoid a claim if it establishes the
probable existence of another health insurance at the time the claim is filed. The MCO shall deny the claim for
coordination of benefits (COB) and return it back to the provider noting the third party the MCO believes to be
legally responsible for payment.
If a balance remains after the provider bills the liable third party or the claim is denied payment for a substantive
reason, the provider may submit a claim to the MCO for payment of the balance up to the maximum allowable
Medicaid reimbursement amount.
PAY AND CHASE VS. WAIT AND SEE
The “pay and chase” method occurs when payment is made by the MCO for submitted claims even if a third party
is likely liable, and the MCO then seeks to recoup payments from the liable third party.
The MCO shall reimburse no less than the full amount allowed under Medicaid’s payment schedule, and then seek
recovery of payment from the third party within 60 days after the end of the month in which payment is made (or
within 60 days after the end of the month the MCO learns of the existence of a liable third party) when:
The service is Preventive Pediatric Care (PPC), including Early and Preventive Screening, Diagnostic, and
Treatment (EPSDT), EPSDT referral and when well-baby procedure codes 99460, 99462, and 99238 are
billed with diagnosis codes Z38 through Z38.8.
NOTE: The MCO shall use the pay and chase method of payment for preventive pediatric services for individuals
under the age of 21 with other Health Insurance when the pediatric preventive diagnosis code is reported in the
primary position of the claim. Hospitals are not included and must continue to file claims with the health insurance
carriers. Primary preventive diagnoses are confined to those listed on www.lamedicaid.com [link
]. EPSDT referral is
indicated as “Y” in block 24H of the CMS-1500 claim form or “A1” as a condition code on the UB-04 (form locators
18-28).
Section 53102(a)(1) of the Bipartisan Budget Act of 2018 removes prenatal care from pay and chase services.
The MCO must “wait and see” on claims for a service that is provided to an individual on whose behalf child
support enforcement is being carried out by the state Title IV D agency. “Wait and see” is defined as payment of
a claim only after the documentation is submitted to the MCO demonstrating that 100 days have elapsed since
the provider billed the responsible third party and remains to be paid. The MCO shall identify third party liability
enforced by the State Title IV-D agency by initiator code 02 in TPL files transmitted by LDH’s fiscal intermediary.
Refer to the MCO System Companion Guide for the TPL file layout and initiator codes.
The provider can only bill Medicaid for the balance not paid for by the liable third party and payment can only be
made for up to the Medicaid allowable amount.
MCO Manual | THIRD PARTY LIABILITY 255
MANAGING THIRD PARTY LIABILITY FILE EXCHANGES AND
ENROLLEE UPDATES
The LDH TPL contractor discovers, verifies, and adds/updates insurance coverage leads for all Medicaid enrollees.
The TPL contractor completes all insurance coverage lead update requests from MCOs, LDH, providers, and
enrollees within four business hours for urgent requests, and within five business days for non-urgent requests.
Additionally, the TPL contractor performs a monthly data match against all Medicaid enrollees and deliver verified
insurance data to the fiscal intermediary within 30 days of the match.
LDH defines urgent TPL requests as the inability of an enrollee to have a prescription filled or the inability of an
enrollee to access immediate care because of incorrect third party insurance coverage.
The LDH TPL contractor is the sole source for electronic TPL resource file add/updates. Responsibilities for each
entity are as follows
12
:
The TPL contractor sends daily TPL file exchanges to the fiscal intermediary.
The fiscal intermediary sends daily incremental TPL files to the MCOs every business day.
Every Monday, the fiscal intermediary sends weekly TPL full reconciliation files to the MCO.
The MCOs submit daily general TPL add/update requests to the TPL contractor via e-mail or fax on the
Daily General MCO TPL Request Form.
o E-mail: [email protected]m
o Fax: 1-877-204-1325
o Phone: 1-877-204-1324
o Hours of Operation: Monday - Friday, 8 a.m. - 5 p.m. Louisiana state holidays are excluded.
If the MCO receives a non-urgent TPL add/update request from a provider or enrollee (past or current P
or B enrollment), the MCO shall refer the provider or enrollee to the TPL contractor and provide contact
information.
When the MCO identifies TPL via claims data (an Explanation of Benefits from the primary carrier), the
MCO shall verify and effectuate the verified update in its system, and process the claim. By close of
business the same day, the MCO shall send the add/update record to the TPL contractor via the Daily
General MCO TPL Update Request Form.
For urgent TPL update requests:
o The MCO shall be responsible for all urgent TPL update requests for P-enrolled enrollees.
The MCO shall verify the request and update its system within four business hours of
receipt of the urgent request. This includes updates on coverage, including removal of
coverage that existed prior to the enrollee’s linkage to the MCO that impacts the current
provider adjudication or enrollee service access (i.e., pharmacy awaiting TPL update to
fulfill prescription).
These updates shall be submitted to the TPL contractor on the day the updates are made
in the MCO's system. The updates shall be submitted via fax or e-mail on the LDH
Medicaid Recipient Insurance Information Update Form. The Submission Status shall be
reported as “Urgent Update: pharmacy awaiting update to fill prescription/member
12
Except as approved by LDH. As of the original date of publication, two of the MCOs submit TPL updates directly to the fiscal
intermediary.
MCO Manual | THIRD PARTY LIABILITY 256
unable to access immediate care”. Urgent TPL requests originating from providers and
LDH via fax and e-mail may be submitted to the TPL contractor using the same Medicaid
Insurance Recipient Information update form submitted to the MCO. Missing policy and
enrollee information shall be added to the request prior to sending to the TPL contractor.
o All urgent TPL requests for B-enrolled enrollees shall be sent to the TPL contractor via phone, e-
mail, or fax.
If the MCO receives an urgent request from a provider or enrollee for a B-enrolled
enrollee, the MCO shall refer the provider or enrollee to the TPL contractor and provide
contact information.
POST-PAYMENT RECOVERIES FROM PROVIDERS AND LIABLE
THIRD PARTIES
Post-payment recovery for third party liability (TPL)/coordination of benefits (COB) is necessary in cases where
the MCO has not established the probable existence of third party liability for payments already made when a
legally obligated third party is later identified.
The following requirements apply to MCOs and their subcontractors for recoveries from providers for TPL:
The MCO or its subcontractor shall seek recovery of reimbursement within 60 days after the end of the
month it learns of the existence of the liable third party.
The MCO or its subcontractor shall seek recovery from the provider where dates of services (DOS) are 10
months or less from the date stamp on the provider recovery letter.
The MCO or its subcontractor shall not seek recovery from the provider where DOS is older than 10
months but shall seek recovery directly from liable third parties. The MCO or its subcontractor may utilize
Act 517 of the 2008 Regular Legislative Session to seek recovery of reimbursement from liable third parties
for up to 36 months from the date of service reported on the claim.
Providers shall have 60 days from the date stamp of the recovery letter to refute the recovery, otherwise
recoupment from future RAs shall occur.
Providers shall be given an additional 30 day extension at their request when the provider billed the liable
third party and hasn’t received an EOB.
If after 60 days of the recovery letter, or 90 days if a 30-day extension was requested, the MCO or its
subcontractor has not received a response from the provider, the recovery shall be initiated.
The provider post-payment recovery notification letter should, at a minimum, include the following:
Provider information (provider number, provider name, provider NPI/Tax ID);
Policy Holder information (name, policy number, group number);
Carrier information (carrier name, address, phone);
Type of coverage (major medical, major medical no maternity, RX only etc.);
Patient information (name, Medicaid ID, DOB);
Line item payment information (Medicaid claim reference number, patient Medicaid number, Medicaid
remit date, dates of service, amount to be recouped);
Recovery totals; and
Contact information to request an extension.
MCO Manual | THIRD PARTY LIABILITY 257
The MCO shall initiate an automatic recoupment at the expiration of the 60-day period if an extension request is
not received from the provider and at the expiration of the 90-day period if an extension is requested by the
provider if the provider has not remitted the payment to the MCO.
Exclusions to Post-Payment Recoveries from Providers
Pay and chase claims will always be referred directly to the liable third parties, as required in the Contract.
Claims billed with EOB denial from other health insurance are excluded.
If the liable third party is traditional Medicare, Tricare, or Champus VA, and more than 10 months have
passed since the DOS, the MCO shall recover from the provider.
Point of Sale (POS) will always be referred directly to liable third parties.
Encounters for Post-Payment Recoveries
The MCO shall adjust both the provider claim record and the encounter record to include the other payer payment
information and report the adjusted MCO payment amount.
TPL SCOPE OF COVERAGE
The type of enrollee’s other health insurance coverage is defined by LDH as scope of coverage. Scope of coverage
codes with associated definitions are specified in the MCO System Companion Guide.
The MCO must accept scope of coverage codes from LDH’s fiscal intermediary in daily and weekly TPL file
transmittals. The fiscal intermediary’s TPL file transmittal schedule and file layout are specified in the MCO System
Companion Guide.
Provider Portal Response for TPL Scope of Coverage
The MCO shall provide its enrollee’s scope of coverage on its provider web portal. This may be the description of
the scope of coverage (e.g., Major Medical No Maternity) or the scope of coverage code associated with the
description (e.g., 27).
TPL scopes of coverage are available on www.lamedicaid.com [link
].
Utilization of Scope of Coverage 27 (Major Medical, No
Maternity Benefits) and 33 (HMO, No Maternity Benefits)
It is possible for Medicaid beneficiaries to have Major Medical Health coverage that excludes maternity benefits.
The LDH TPL contractor will assign scope of coverage (SOC) 27 to Major Medical Health Insurance Policies without
Maternity Benefits and HMO Major Medical Insurance Policies without Maternity Benefits. HMO Major Medical
Insurance Policies without Maternity Benefits (formerly SOC 33) has been consolidated into SOC 27.
The MCO shall not cost avoid maternity claims for enrollees with other health insurance whose Major Medical
Health Insurance benefit (SOC 27) or HMO Major Medical Health Insurance benefit (SOC 27) excludes maternity
MCO Manual | THIRD PARTY LIABILITY 258
benefits. If the MCO or its subcontractor identifies TPL, it must determine if the coverage being added or updated
meets the maternity exclusion.
MCOs must work with its staff and subcontractors who identify and/or verify TPL to determine if the coverage
being added meets the maternity exclusion criteria.
MCOs must work with their providers to develop a process to allow providers to update the scope of coverage to
27.
*Both the diagnosis code and the TH modifier are required.
LAHIPP
LaHIPP participants may be identified in 834 eligibility files by CAP codes as specified in the Healthy LA MCO MVX
COA Crosswalk or by TPL initiator code 25 in the TPL file layout as specified in the MCO System Companion Guide.
LDH is responsible for issuing payment for all or part of LaHIPP participants’ health insurance premium.
LaHIPP enrollees are mandatorily enrolled in Medicaid managed care for specialized behavioral health services,
and non-emergency medical transportation, including non-emergency ambulance transportation, unless residing
in an institution. LaHIPP participants who receive coverage via the Act 421 Children’s Medicaid Option are
mandatorily enrolled in Medicaid managed care for all Medicaid covered services
Calculation of Payment for LaHIPP Secondary Claims
Claims processed by the MCO as secondary payer for LaHIPP enrollee claims shall be processed and paid by the
MCO at the full patient responsibility (co-pay, co-insurance, and/or deductible) regardless of Medicaid’s allowed
amount, billed charges or TPL payment amount if the participant uses a provider that accepts the enrollee’s
insurance as primary payer and Medicaid as secondary payer. If the provider does not accept this payment
arrangement, the participant shall be responsible for the enrollee liability. The MCO pays only after the third party
has met the legal obligation to pay. The MCO is always the payer of last resort, except when the MCO is responsible
for payment as primary payer for Medicaid covered services not covered by commercial insurance as primary
payer (e.g., mental health and transportation services).
The following is a LaHIPP claims processing example:
Procedure Code
Billed Charge
TPL Paid
Amount
Medicaid Allowed
Amount
Patient Responsibility
Amount
Medicaid
Payment
99213
70.00
40.00
36.13
10.00
10.00
Because this is a LaHIPP enrollee, Medicaid pays the co-pay even though the private insurance payment is more
than the Medicaid allowable. Medicaid pays the patient responsibility on Medicaid covered services regardless of
Medicaid’s allowed amount, billed charges, or TPL payment.
NOTE: Refer to the Resources section for a link to the Reinstatement and Implementation of LAHIPP Third Party (TPL) Claims
Payment manual for more LaHIPP claims processing examples.
MCO Manual | THIRD PARTY LIABILITY 259
TPL PAYMENT & TPL PAYMENT CALCULATION
If a TPL insurer requires the enrollee to pay any co-payment, coinsurance or deductible, the MCO is responsible
for making these payments under the method described below, even if the services are provided outside of the
MCO network.
Scenario 1 Professional Claim
Procedure
Code
Billed Charge
TPL Paid
Amount
Medicaid
Allowed
Amount
Patient Responsibility
Amount
Medicaid Payment
99212
55.00
0.00
24.10
36.00 (Ded)
24.10
83655-QW
30.00
0.00
11.37
28.20 (Ded)
11.37
Totals
85.00
0.00
35.47
64.20 (Ded)
35.47
The Medicaid allowed amount minus the TPL paid amount is LESS than the patient responsibility; therefore, the
Medicaid allowed amount is the payment.)
Scenario 2 Outpatient Claim
Procedure
Code
Billed Charge
TPL Paid
Amount
Medicaid
Allowed Amount
Patient Responsibility
Amount
Medicaid Payment
HR270
99.25
74.44
22.04
0.00
0.00
HR450
316.25
137.19
70.24
100.00
0.00
Total
415.50
211.63
92.28
100.00
0.00
(Medicaid “zero pays” the claim. When cost-compared, the private insurance paid more than Medicaid allowed
amount for the procedure. When compared, the lesser of the Medicaid allowed amount minus the TPL payment
AND the patient responsibility is the former; thus, no further payment is made by Medicaid. The claim is paid in
full.)
Scenario 3 Inpatient Claim
Procedure
Code
Billed Charge
TPL Paid
Amount
Medicaid
Allowed Amount
Patient Responsibility
Amount
Medicaid Payment
Multiple HR
12,253.00
2,450.00
5,052.00
300.00
300.00
(The Medicaid allowed amount minus the TPL payment is greater than the patient responsibility; thus, the patient
responsibility is paid on this covered service.)
Scenario 4: FQHC/RHC/American Indian Clinic
Provider’s PPS
Rate (Medicaid
allowable)
Procedure Code
Billed Charge
TPL Paid Amount
Patient Responsibility
Amount
Medicaid Payment
150.00
T1015
150.00
50.00
40.00 (Ded)
100.00
Provider’s PPS rate is $150.00. The third party paid $50.00. Medicaid pays the difference from the PPS rate and
third party payment making the provider whole.
MCO Manual | THIRD PARTY LIABILITY 260
MCOs may not establish a cost-sharing payment methodology for enrollees with third party liability for FQHC, RHC
and American Indian Clinic services at less than the Louisiana Medicaid State Plan rate (PPS). MCOs must pay the
difference between the third party payment and the PPS for the service.
MCO payment = Medicaid PPS Rate - TPL paid amount
Scenario 5 Outpatient Pharmacy Claim
Amount Billed
TPL Paid
Amount
Medicaid
Maximum
Allowable
Patient Responsibility
Amount from Primary
Medicaid
Pharmacy
Co-Pay
Medicaid Payment
38.55
28.55
31.36
10.00 (Copay)
0.50
2.31
613.00
60.00
40.73
553.00 (Ded)
0.00
0.00
177.97
5.22
14.39
172.75 (Ded)
0.50
8.67
If third party liability (TPL) is involved, the MCO as the secondary payer may not deny the claim for a high dollar
amount billed for claims less than $1,500. If the TPL pays $0.00 or denies the claim, then the pharmacy claims
should be treated as a straight Medicaid pharmacy claim. Taxes on the primary claim should be subtracted before
calculating the Medicaid Maximum Allowable. Maximum Medicaid allowable is defined as professional dispensing
fee plus ingredient cost (quantity * price per unit) or usual and customary, whichever is less.
The pricing calculation is ingredient cost (quantity * price per unit) + Dispensing Fee – TPL amount paid –
copayment = Medicaid payment. If U&C is less than the Medicaid allowable, then the calculation is U&C – TPL
amount paid – copayment = Medicaid payment. If there is other third party liability (TPL) payment greater than
$0.00, the MCO should electronically bypass prior authorization requirements and Point of Sale edits that would
not be necessary as the secondary payer. Safety edits should still apply.
TPL claims should process with the same PCN and BIN number as primary claims.
Scenario 6: LaHIPP Enrollee Claim
Procedure Code
Billed Charge
TPL Paid
Amount
Medicaid Allowed
Amount
Patient Responsibility
Amount
Medicaid
Payment
99213
70.00
40.00
36.13
10.00
10.00
Because this is a LaHIPP enrollee, Medicaid pays the co-pay even though the private insurance payment is more
than the Medicaid allowable. Medicaid pays the patient responsibility on Medicaid covered services regardless of
Medicaid’s allowed amount, billed charges, or TPL payment.
LIENS (TRAUMA RECOVERY)
Approval Guidelines for Trauma Recovery Lien Settlements
Equal to or Greater Than $25,000
The process for obtaining LDH approval for settlements on liens equal to or greater than $25,000 is as follows:
MCO Manual | THIRD PARTY LIABILITY 261
The LDH subject matter expert (SME)/business owner for the TPL Trauma Recovery process is the point
of contact for these submissions. The MCO must provide LDH with its contact for this process.
The MCO (not its subrogation vendor) must submit these requests directly to LDH via e-mail, marked with
High Importance, using the following subject format: “[MCO Name], Settlement Request”.
At minimum, the MCO must include the following in the body of the e-mail and/or in the corresponding
attachment(s):
o Enrollee’s identifying information (name, SSN, Medicaid ID#);
o DOA/DOI (Date of Accident/Date of Incident);
o Third party (i.e., liable party/insurance companies, defense and plaintiff attorneys), with contact
information;
o MCO’s lien amount;
o Case settlement amount;
o Requested settlement amount (suggested reduced amount);
o Description of incident and injuries;
o Reason for request and MCO’s recommendation;
o Other liens to be considered; and
o Attorney’s fees and expenses.
Once received, the LDH SME/business owner will consult with LDH Bureau of Legal Services and provide
its decision to the MCO’s contact via secure e-mail.
Guidelines for Prior Notice of Trauma Recovery Subrogation
Vendor and Process Changes
MCOs shall notify LDH of any changes to the Trauma Recovery subrogation vendor, contact, or process via e-mail
at Medicaid.TraumaEstate[email protected]v
(cc: LDH business owner) at least 30 days prior to implementation of
changes. MCOs shall provide the following information within the e-mail as applicable:
Vendor/entity name;
Contact person;
Mailing address;
Phone number;
Fax number;
E-mail (including for referrals from LDH); and
Detailed process changes (e.g., effective dates, cutoff date/process for vendor transition, subpoena
process server).
MCO Manual | THIRD PARTY LIABILITY 262
COORDINATION OF BENEFITS
Other Coverage Information and Third Party Liability Data
Exchange
In a format and medium specified by LDH in the MCO System Companion Guide, the MCO shall submit to LDH or
its contractor a daily TPL file reporting verified TPL additions and updates for each enrollee that has not otherwise
been provided by LDH’s fiscal intermediary.
The MCO shall review daily response files from LDH, or its contractor, and rejected records shall be corrected and
completed within five business days.
If an enrollee is unable to access services or treatment until an update is made, the MCO shall verify and update
its system within four business hours of receipt of an update request. This includes updates on coverage, including
removal of coverage that existed prior to the enrollee’s linkage to the MCO that impacts current provider
adjudication or enrollee service access. Such updates shall be submitted to LDH and/or its TPL vendor on the
Medicaid Recipient Insurance Update Form [link
].
Reporting and Tracking
The MCO’s system shall identify and track potential collections. The system should produce reports indicating
open receivables, closed receivables, amounts collected, amounts written off, and amounts avoided.
MCO Manual | SYSTEMS AND TECHNICAL REQUIREMENTS 263
PART 18: SYSTEMS AND TECHNICAL
REQUIREMENTS
The MCO shall maintain an automated Management Information System (MIS), hereinafter referred to as System,
which accepts and processes provider claims, verifies eligibility, collects and reports encounter data, and validates
prior authorization and pre-certification that complies with LDH and federal reporting requirements.
GENERAL REQUIREMENTS
The MCO shall ensure that its System meets the requirements of the MCO System Companion Guide.
HIPAA STANDARDS AND CODE SETS
Data elements and file format requirements may be found in the MCO System Companion Guide.
CONNECTIVITY
The System shall conform and adhere to the data and document management standards of LDH and its fiscal
intermediary, inclusive of standard transaction code sets as outlined in the MCO System Companion Guide.
HARDWARE AND SOFTWARE
The MCO shall maintain hardware and software compatible with current LDH requirements which are as follows.
This includes, but is not limited to, call center operations, claims EDI operations, authorized services operations,
and enrollee services operations.
Desktop Workstation Hardware
IBM-compatible, networked PC running Microsoft Windows 7 or later operating system.
Desktop Workstation Software
Operating system should be Microsoft Windows 7 or later,
Web browser that is equal to or surpasses Microsoft Internet Explorer v7.0 and is capable of resolving
JavaScript and ActiveX scripts;
An e-mail application that is compatible with Microsoft Outlook 2007 or later. The e-mail application
should have the ability to send secure messages in the case that Protected Health Information (PHI) is
present. E-mail users should be periodically (at least annually) trained in the appropriate use of secure e-
mail functionality with respect to PHI;
An office productivity suite such as Microsoft Office that is compatible with Microsoft Office 2007 or later;
Each workstation should be networked and have access to high speed Internet;
MCO Manual | SYSTEMS AND TECHNICAL REQUIREMENTS 264
Each workstation connected to the Internet should have anti-virus, anti-spam, and anti-malware software.
Regular and frequent updates of the virus definitions and security parameters of these software
applications should be established and administered;
A desktop compression/encryption application that is compatible with WinZIP v11.0;
All contractor-utilized workstations, laptops and portable communication devices shall be:
o Protected by industry standard virus protection software which is automatically updated on a
regular schedule;
o Have installed all security patches which are relevant to the applicable operating system and any
other system software; and
o Have encryption protection enables at the Operating System level.
Compliant with industry-standard physical and procedural safeguards for confidential information (NIST
800-53A, ISO 17788, etc.).
NETWORK AND BACK-UP CAPABILITIES
The MCO shall:
Establish a local area network or networks as needed to connect all appropriate workstation personal
desktop computers (PCs);
Establish appropriate hardware firewalls, routers, and other security measures so that the MCO's
computer network is not able to be breached by an external entity;
Establish appropriate back-up processes that ensure the back-up, archival, and ready retrieval/recovery
of mainframe (when applicable), network server data and desktop workstation data;
Ensure that network hardware is protected from electrical surges, power fluctuations, and power outages
by using the appropriate uninterruptible power system (UPS) and surge protection devices; and
Establish independent generator back-up power capable of supplying necessary power for a minimum of
four calendar days.
PROVIDER ENROLLMENT
Provider enrollment systems shall include, at minimum, the following functionality:
Audit trail and history of changes made to the provider file;
Automated alerts when provider licenses are nearing expiration;
Retention of NPI requirements;
System generated letters to providers when their licenses are nearing expiration;
Linkages of individual providers to groups;
Credentialing information;
Provider office hours; and
Provider languages spoken.
MCO Manual | RESOURCES 265
RESOURCES
MANUALS AND GUIDES
Links to manuals and guides referenced in this Manual are provided below. Additional MCO resources are posted
on the LDH website [link
].
Chisholm Compliance Guide and MCO User Manual
Crisis Response System Companion Guide
DOJ Agreement Compliance Guide
Continuity of Operations Plan
Financial Reporting Guide
Justice-Involved Pre-Release Enrollment Program Manual
Louisiana Quality Management Strategy for the Louisiana Medicaid Managed Care Program (Quality
Strategy)
Louisiana Medicaid 837 Health Care Claim Companion Guides
Louisiana Medicaid HIPAA 5010A General Companion Guide
Marketing and Member Education Companion Guide and additional resources
Medicaid 834 Benefit and Enrollment EDI Transaction Set Companion Guide (834 Systems Companion
Guide)
Medicaid Services Manual
Physician Incentive Plan Requirements
Provider’s Bill of Rights
Quality Companion Guide
Reinstatement and Implementation of LAHIPP Third Party (TPL) Claims Payment
State Directed Payment Program Manual
State Fair Hearing Companion Guide
System Companion Guides
FEE SCHEDULES
Louisiana Medicaid FFS fee schedules are posted on www.lamedicaid.com [link].
FORMS AND TEMPLATES
Most forms referenced in this Manual may be located at www.lamedicaid.com [link].
Additional forms referenced in this Manual may be located using the following links:
Denial and Partial Denial Notice Templates
LDH Provider Fraud Referral Form (placeholder)
Louisiana Standardized Credentialing Application
Marketing Complaint Submission Form
Material Subcontractor Checklist
