Provider FAQ: Auths/Referrals/Covered Services

What happens when a patient comes into our office and we find he is not linked to our Health Plan?

Unless it is an emergency, the patient should be referred to the PCP the Health Plan has assigned him/her, if the patient knows who the PCP is. If not, the patient can be referred to the Health Plan’s Member Services toll-free number. The name of the patient's Health Plan can be determined by the eligibility verification system, which will be maintained for providers by Gainwell Technologies.

How difficult is it to link a patient not in our Health Plan to our Health Plan?

Providers do not directly link patients to a Health Plan. Medicaid and LaCHIP enrollees select their Health Plans and indicate their preferred provider or, if no choice is made, they are assigned to a Plan. During the first 90 days of enrollment, enrollees can change Plans for any reason. After the initial 90 days, the patients are locked into that Health Plan until the next open enrollment, unless they have good cause to change Plans. Patients wishing to change Health Plans should be referred to the Enrollment Center’s toll-free number, 1-855-229-6848. Patients wishing to change doctors should be referred to their Health Plan’s Member Services toll free number.

How does LDH handle those patients that have Medicaid as a secondary insurance?

Medicare Dual eligibles are excluded from Health Plan enrollment. For members with commercial insurance as the primary payer, Medicaid via the Health Plan will be the payer of last resort.

How do we verify eligibility?

Eligibility can be verified with the Web, phone and swipe card options in the eligibility verification system operated by DXC Technology.

Are Health Plans required to reimburse the current rates for provider based RHCs, or are they required to reimburse based on the cost + 10% formula for the duration of the contract?

Health Plans pay RHC claims based on the Medicaid PPS rate for that RHC in effect on the date of service. In addition, the existing cost settlement methodology has not changed.

In regard to non-emergency reimbursement, is the reimbursement 90% rate based on the CPT used?

The “not more than 90%” reimbursement rate is based on the Medicaid fee schedule or the Health Plans fee-schedule if greater than Medicaid.

What fee schedule is used?

The minimum fee schedule is in the Medicaid fee schedule in effect on the date of service. Differences in a Health Plan’s fee schedule (if applicable) can be obtained directly from that Health Plan.

How does managed care affect independent laboratories?

It is dependent on the contract between the Health Plan and the lab.

How does Healthy Louisiana affect dentists?

Medicaid dental benefits statewide are managed by DentaQuest and MCNA Dental. Most but not all Medicaid and LaCHIP recipients will be enrolled in a Dental Plan. Recipients that are enrolled in a Dental Plan do not have the option to continue to receive dental services through legacy Medicaid, while some recipients are excluded from a Dental Plan. Providers must be credentialed with DentaQuest and/or MCNA to administer dental services to eligible Medicaid recipients.

What do the Health Plans do that Medicaid hasn’t done in the past?

Health Plans can ensure better coordination of member services, and will ease the burden on providers by assuming responsibility for referrals, care management services and disease management services. Health Plans have more flexibility to restructure resources. The Plans are better able to support providers by assisting with issues such as transportation, referrals and patient compliance that can be problematic in the current program. The networks better support providers in dealing with problematic patients so doctors do not have to expend the time and resources to do so.

How does authorization for non-emergency room, non PCP, outpatient primary care visits work?

Please refer to the  Health Plans' Provider Handbooks or direct this question to the Health Plans' Provider Relations, as each Plan has  established their own authorization policies. (which do require approval from LDH).

Can a recipient choose a specialist as their PCP?

It depends on the Health Plan's policy. Check with your Health Plan first.

Do outpatient surgeries require prior authorization?

Prior authorizations are not required for any outpatient surgical procedures. However, if the procedure is performed on the 1st or 2nd day of the inpatient’s stay a pre-cert is needed.

If a recipient goes to the ER, can they go to any hospital?

Yes, the recipient can go to any ER. The Health Plan must cover and pay for emergency services regardless of whether the provider that furnishes the emergency services has a contract with the Health Plan. If an emergency medical condition exists, the Health Plan is obligated to pay for the emergency service.

If a physician sends a patient to our facility to have a CT Scan for a diagnostic test, can we proceed with testing if we are not contracted with the patient's Health Plan?

Please contact the Health Plans' Provider Relations departments for clarification on their prior authorization requirements. They may differ between the Plans.

If we provide emergent care to a patient that comes into the ER, and he is admitted, do we have to transfer him out of the facility when he’s stabilized, or do we seek prior authorization for continued care?

According to the contract, the Health Plan is financially responsible for post-stabilization care services rendered out of network when pre-approved by a Health Plan representative or provider; or not pre-approved but administered within one hour of requesting prior authorization to maintain the patient's stabilized condition.

Are claims handled through Gainwell Technologies? Do patients still need to get referrals?

Gainwell Technologies, Medicaid's fiscal intermediary, handles claims processing and payment for FFS members. The Health Plans handle claims directly. The Health Plans, not the providers, are responsible for making patient referrals and ensuring access to specialty care, reducing the burden on providers.

Are home health agencies contracting with the Healthy Louisiana Plans?

Yes. The Health Plans are contracting with home health agencies.