Managed Care Policies & Procedures

"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.

Below are the changes to the managed care policies and procedures beginning August 1, 2019. To provide feedback, please complete this form.

Item Number Policy/Procedure Date Posted Public Comments Due By Status Document Links
 2019-HBL-1  Modifier Usage RP (4.19.19)  8/13/19  9/27/19  Pending  BLA-RP-0135-19 Modifier Usage
 2019-HBL-2  Modifier 62 (8.1.19)  8/13/19  9/27/19  Pending  BLA-RP-0149-19 Modifier 62
 2019-HPA-1  Severe Combined Immunodeficiency (SCID)  8/27/19  10/11/19  Pending  HPA - SCID
2019-SCG-1  Edit 472 disposition to be changed from "E" to "D" [deny]. 9/10/19 10/25/19 Pending  MCO System Companion Guide, pg. 128
2019-SCG-2  LDH stopped using self-reported data in 2018; the 416 reports are generated from MCO encounter data. 9/10/19 10/25/19 Pending MCO System Companion Guide, pg. 117
2019-IB-1 Proposed retirement of Informational Bulletin 16-1 9/12/19 10/27/19 Pending IB 16-1
2019-DUR-1 Pharmacy Drug Utilization Review (DUR) Criteria 9/13/19 10/28/19 Pending Pharmacy DUR Criteria effective 11/1 and 12/1
2019-HBL-20 Semi Annual Cost of Care Review 9/13/19 10/28/19 Pending BLA-NL-0148-19
2019-UHC-27 UHC Prior Authorization LA Effective 9.1.19 9/13/19 10/28/19 Pending UHC Prior Authorization LA Effective 9.1.19
2019-UHC-29 Pharmacogenetic Testing 9/20/19 11/4/19 Pending Pharmacogenetic Testing