Current through Register Vol. 50, No. 9, September 20, 2024
B. Medicaid claims
for services covered under the State Plan will be cost avoided when there is
probable third party liability unless the claim is for one of the following
services:
1. primary preventive pediatric
care diagnoses are confined to those listed under
Diagnosis Codes
Related to Preventive Pediatric Care Services at
www.lamedicaid.com;
a. Individuals under age 21 qualify;
and
b. Hospitals are not included
and must continue to file claims with the health insurance
carriers;
2. early and
periodic screening, diagnosis and treatment (EPSDT) medical, vision, and
hearing services;
3. EPSDT dental
services;
4. EPSDT services to
children with disabilities (formerly referred to as school-based health
services) which result from screening and are rendered by school
boards;
5. services which are a
result of an EPSDT referral, indicated by entering "Y" in block 24H of the
CMS-1500 claim form, sometimes called HCFA-1500, or "1" as a condition code on
the UB-92 (form locators 24 through 30); and
6. services for Medicaid eligibles whose
health insurance is provided by an absent parent who is under the jurisdiction
of the state child support enforcement agency are subject to a "wait and see
period" that was effective April 1, 2021.
a.
Wait and See-payment of a claim only after documentation is
attached to a hard copy claim and submitted to the state's fiscal intermediary
demonstrating that 100 days have elapsed since the provider billed the
responsible third party and remains to be paid.
C. In processing these claims, the Medicaid
agency will pay the claim and seek reimbursement from liable third parties,
utilizing the claims method of payment called "pay and chase".
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
