Frequently Asked Questions

How will the fee schedule be determined for new codes that come out each year?

The current Medicaid fee schedule process will continue and will be communicated to the Health Plans.

Do you have to participate with the Health Plans to receive Medicaid secondary payment?

Medicare Dual Eligibles are excluded from managed care and will continue to be enrolled in Medicaid fee-for-service. Other Medicaid enrollees who have another insurance as primary with Medicaid as secondary are enrolled with a Health Plan. To receive Medicaid secondary payment from a Health Plan for a core benefit or service provided to a Plan member, the provider must participate with the Health Plan.

How does billing work?

Providers should follow the billing procedure instructions for the Plans with which they are enrolled. Health Plans are asked to provide this information up front and keep the process transparent to assist providers.

What is the fixed rate floor equal to compared with fee for service?

The manged care rate floor will be equal to the published Medicaid rate in place on the day that service is performed.

What constitutes a clean claim? Can providers see examples?

As specified in the contract, the Health Plans must keep their clean claims processes as transparent as possible for providers in their networks. The Plans must provide clean claim examples to their providers so providers can be prepared to submit claims and receive timely reimbursement for their services.

For Medicaid fee-for-service, federal guidelines specify what constitutes a clean claim.

The current Per Diems contain Medical Education as part of my institution's per diem since we are a major teaching hospital, do the Health Plans make these payments?

No, LDH will reimburse qualifying hospitals for GME.

Currently my institution does not bill Pre Evaluation services and includes these charges in the Medicaid Cost Report. I have been told that these charges should be billed to the Health Plans. In addition will there still be settlement on the Cost Report for Transplant?

Cost report settlement will still be calculated. LDH will only be responsible for payment of cost settlement for FFS. LDH is not responsible for payment of cost settlement on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

Should we bill LDH or the Health Plans for hemophilia costs in excess of $50,000 on a patient by patient basis?

LDH will only be responsible for payment of hemophilia outliers for FFS. LDH is not responsible for payment of hemophilia outliers on services paid through capitated rates. Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

With the increase in per diems for NICU and PICU the volume of outliers will decrease, however is the Health Plan or LDH still responsible for Outlier Payments?

LDH will only be responsible for payment of outliers for FFS. LDH is not responsible for payment of outliers on services paid through capitated rates. . Whether the MCO pays is dependent on the hospital’s negotiated payment rates with the MCO.

In my practice, if a person has a Medicaid application pending, we typically hold the billing for service for three months since it can take up to 90 days for Medicaid eligibility to be determined for new applicants. If eligibility is granted, should we bill Molina or the patient's Health Plan?

Enrollment in a Health Plan will always be for a future month following a patient being added to the Medicaid eligibility file so you would continue to bill Medicaid fee-for-service as you currently do for the retroactive period of Medicaid eligibility. Molina will be the payer before the approval date and the month of approval and depending on timing, they could be in fee-for-service as long as two months following their month of approval (The only exception is a newborn who is retroactive to the date of birth). The timely filing limit for Bayou Health claims is 365 days. This includes claims submitted to Health Plans or any of their sub-contractors, and we are clarifying that for the Health Plans.

Are the Health Plans able to accept electronic claims in the X12 835 format?

Yes