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					RURAL HEALTH CLINICS
  PROVIDER MANUAL
Chapter Forty of the Medicaid Services Manual



          Issued December 1, 2010




                     State of Louisiana
                     Bureau of Health Services Financing
LOUISIANA MEDICAID PROGRAM                             ISSUED:              10/19/12
                                                    REPLACED:               08/01/12
CHAPTER 40: RURAL HEALTH CLINICS
SECTION: TABLE OF CONTENTS                                                PAGE(S) 3


                         RURAL HEALTH CLINICS

                            TABLE OF CONTENTS

SUBJECT                                                                   SECTION

OVERVIEW                                                            SECTION 40.0

COVERED SERVICES                                                    SECTION 40.1

    Physician Services
    Services and Supplies Incident to a Physician’s Professional Services
    Physician Assistant Services
    Nurse Practitioner and Nurse Midwife Services
    Services and Supplies Incident to Physician Assistant, Nurse Practitioner and Nurse
    Midwife Services
    Visiting Nurse Services
           Plan of Treatment
    Clinical Psychologist Services
    Clinical Social Worker Services
    Services and Supplies Incident to the Services of Clinical Psychologists and
    Clinical Social Workers
    Basic Lab Services
    Other Ambulatory Services
    Diabetes Self-Management Training
    Encounter
    Service Limits
           Request for Emergent or Life Threatening Conditions
    Exclusions
    Service Delivery

PROVIDER REQUIREMENTS                                               SECTION 40.2

    Location
    Shortage Area Designation
    Staffing
    Medicaid Enrollment Criteria
    Diabetes Self-Management Training


                                    Page 1 of 3                     Table of Contents
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SECTION: TABLE OF CONTENTS                                             PAGE(S) 3

    Satellite Clinics
    Mobile Clinics
    Out of State RHCs in Trade Areas
    Change in Ownership
    Cost Reports
    Medicare Certification

RECORD KEEPING                                                   SECTION 40.3

    Record Maintenance and Availability
    Protection of Record Information
    Adequacy of Records
    Retention of Records

REIMBURSEMENT                                                    SECTION 40.4

    Rates
           Determination of Rate
           Alternative Payment Methodologies
           Adjustment of Rate
           Out of State/Trade Area RHC
           Notice of Rate Setting
           Appeals
    Cost Report Submission
           Audits
    Encounter Visits
           Payment for Adjunct Services
    Billing
           Medical/Behavioral Encounters
            Adjunct Services
            Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screening
            Services
            Dental Encounters
            Medicare/Medicaid Dual Eligible Billing
            Outpatient Services
            Inpatient Services

CONTACT INFORMATION                                                APPENDIX A


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SECTION: TABLE OF CONTENTS                              PAGE(S) 3


FORMS                                               APPENDIX B

GLOSSARY                                            APPENDIX C

CLAIMS FILING                                       APPENDIX D




                        Page 3 of 3                Table of Contents
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                12/01/10
                                                            REPLACED:                 11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.0: OVERVIEW                                                             PAGE(S) 1

                                        OVERVIEW
The Rural Health Clinic (RHC) program was established through the Rural Health Clinic Act of
1977 to address an inadequate supply of primary health care providers who serve Medicare and
Medicaid beneficiaries in rural areas. The program provides qualifying clinics located in rural
and medically underserved communities with a prospective reimbursement methodology
described under Section 1902(bb) of the Social Security Act.

RHCs may be either provider-based clinics or independent clinics. The provider-based RHC is
considered an integral part of a rural hospital, nursing home or home health agency that is a
Medicare certified provider. An independent RHC is any other clinic which meets the
requirement to be classified as a RHC and is owned and operated by any entity as long as it is not
operated as a rehabilitation agency or a facility primarily for care and treatment of mental
diseases.

The purpose of this chapter is to set forth the conditions and requirements that RHCs must meet
in order to qualify for reimbursement under the Louisiana Medicaid program. The manual is
intended to make available to Medicaid providers of RHC services a ready reference for
information and procedural material needed for the prompt and accurate filing of claims for
services furnished to Medicaid recipients.
The Department of Health and Hospitals, Bureau of Health Services Financing (BHSF), Program
Operations Section is responsible for assuring provider compliance with these regulations.




                                           Page 1 of 1                               Section 40.0
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CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.1: COVERED SERVICES                                                       PAGE(S) 9

                                     COVERED SERVICES

A Rural Health Clinic (RHC) provides core services in addition to other ambulatory services.
The core services provided by RHCs are comprised of the following:

       •       Physician services,

       •       Services and supplies incident to physician’s services,

       •       Physician assistant services,

       •       Nurse practitioners and nurse midwife services,

       •       Services and supplies incident to the services of nurse practitioners, physician
               assistants, and certified nurse midwives,

       •       Visiting nurse services to the homebound,

       •       Clinical psychologist services,

       •       Clinical social worker services,

       •       Services and supplies incident to the services of clinical psychologists and clinical
               social workers, and

       •       Basic lab services.

Physician Services
Physician services are the professional services performed by a physician for a recipient
including diagnosis, therapy, surgery, and consultation.

Physician services are covered if they are professional services performed by a physician at the
clinic; or performed away from the clinic if the physician has an agreement with the clinic to be
paid for the services. The services must be in the scope of his/her profession under Louisiana
law.

Services and Supplies Incident to a Physician’s Professional Services
Services and supplies incident to a physician’s professional service are covered if the service or
supply is furnished:


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       •       In a physician’s office,

       •       Either without charge or included in the clinic’s bill,

       •       As an incidental, although integral, part of a physician’s professional services,

       •       Under the direct, personal supervision of a physician, and

       •       By a member of the clinic’s health care staff who is an employee of the clinic.

Only drugs and biologicals that cannot be self-administered are included within the scope of this
benefit.

Physician Assistant Services
A physician assistant (PA) is eligible to enroll in Medicaid and must obtain a provider number and
use it on the billing form when performing services or prescribing drugs. PA services are covered
if:
        •       Furnished by a PA who is employed by or receives compensation from the clinic
                and is enrolled in the Louisiana Medicaid Program,

       •       Identified by placing his/her provider number in the attending physician space on
               the CMS 1500,

       •       Furnished under the medical supervision of a physician. The physician
               supervision requirements are met if the conditions specified and any pertinent
               requirements of state law are satisfied.

       •       Furnished in accordance with medical orders for the care and treatment of a
               patient prepared by a physician,

       •       Consistent with the type of service the PA is legally permitted to perform, and

       •       Furnished by a physician and covered by Medicaid.

Nurse Practitioner and Nurse Midwife Services
Services are covered if:




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       •      Furnished by a nurse practitioner or nurse midwife who is employed by or
              receiving compensation from the clinic,

       •      Enrolled in Louisiana Medicaid,

       •      Identified by placing his/her provider number in the attending physician space on
              the CMS 1500,

       •      Furnished under the medical supervision of a physician. The physician
              supervision requirement is met if the conditions specified and any pertinent
              requirements of State law are satisfied.

       •      Furnished in accordance with any medical orders for the care and treatment of a
              patient prepared by a physician,

       •      Performed by a nurse practitioner or mid-wife, who is legally permitted to provide
              this type of service, and

       •      Furnished by a physician and the service is covered by Medicaid.

Nurse practitioners and nurse mid-wives are eligible to enroll in Medicaid and must obtain a
provider number and use it on the billing form when performing services or prescribing
medications.

Services and Supplies Incident to Physician Assistant, Nurse Practitioner and
Nurse Midwife Services
Services and supplies incident to a nurse practitioner, nurse midwife or physician assistant
services are covered if:

       •      Furnished in a physician’s office,

       •      Rendered either without charge or included in the clinic’s bill,

       •      Furnished as an incidental, although integral part of professional services
              furnished by nurse practitioner, PA or nurse midwife,

       •      Furnished under his/her direct, personal supervision. The direct personal
              supervision requirement is met only if the person is permitted to supervise these
              services under the written policies governing the clinic and




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SECTION 40.1: COVERED SERVICES                                                          PAGE(S) 9

        •       Furnished by a member of the clinic’s health care staff who is an employee of the
                clinic.

Only drugs and biologicals that cannot be self-administered are included within the scope of this
benefit.

Visiting Nurse Services
Part time or intermittent visiting nurse care and related supplies are covered if:

        •       The clinic is located in an area designated by CMS as a home health agency shortage
                area,

        •       The services are rendered to a homebound individual. For purposes of visiting nurse
                services, “homebound” means a Medicaid recipient who is permanently or
                temporarily confined to his or her place of residence because of a medical or health
                condition. The individual may be considered homebound if he or she leaves the
                place of residence infrequently. For this purpose, “place of residence” does not
                include a hospital or skilled nursing facility.

        •       The services are furnished by a registered nurse or licensed practical nurse or a
                licensed vocational nurse, which is employed by or received compensation for the
                services from the clinic and

        •       The services are furnished under a written plan of treatment.

Plan of Treatment

The plan of treatment must be established and reviewed at least every 60 days by a supervising
physician of the clinic or established by a physician, nurse, practitioner, physician assistant or nurse
midwife, or specialized nurse practitioner and reviewed and approved at least every 60 days by a
supervising physician. The plan must be signed by the nurse practitioner, physician assistant, nurse
midwife or the supervising physician of the clinic.

The plan of treatment must relate visiting nurse services to the recipient’s condition. The plan must
specify the following:

        •       Types of services required and a long-range forecast of likely changes in the
                recipient’s condition,

        •       Diagnosis and a description of the recipient’s functional limitations resulting from
                the illness or injury,


                                              Page 4 of 9                                 Section 40.1
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SECTION 40.1: COVERED SERVICES                                                         PAGE(S) 9


       •       Type and frequency of nursing services needed,

       •       Special diets,

       •       Activities permitted,

       •       Rehabilitation and therapy services,

       •       Medical social services,

       •       Home health aide-like services, and

       •       Necessary medical supplies.

All changes in orders for dangerous drugs and narcotics must be signed by the physician.

Clinical Psychologist Services
Clinical psychologist services refers to services performed by a clinical psychologist for
diagnosis and treatment of mental illness which the clinical psychologist is legally authorized to
perform under State licensure as would otherwise be covered if furnished by a physician or as an
incident to a physician’s service.

Clinical Social Worker Services
Clinical social worker services refers to services performed by a clinical social worker for diagnosis
and treatment of mental illness which the clinical social worker is legally authorized to perform
under state licensure and such services as would otherwise be covered if furnished by a physician or
as an incident to a physician‘s professional service.

Services and Supplies Incident to the Services of Clinical Psychologists and
Clinical Social Workers
Services are covered if furnished:

       •       In a physician’s office,

       •       Either without charge or included in the clinic’s bill,




                                             Page 5 of 9                                Section 40.1
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SECTION 40.1: COVERED SERVICES                                                      PAGE(S) 9

       •      As an incidental, although integral part of professional services furnished by nurse
              practitioner, PA or nurse midwife,

       •      Under his/her direct, personal supervision. The direct personal supervision
              requirement is met only if the person is permitted to supervise these services
              under the written policies governing the clinic, and

       •      By a member of the clinic’s health care staff who is an employee of the clinic.

Only drugs and biologicals that cannot be self-administered are included within the scope of this
benefit.

Basic Lab Services
An RHC is required to provide the following minimum lab services on site:

       •      Chemical examinations or urine by stick or tablet methods, or both,

       •      Hemoglobin or hematocrit,

       •      Blood sugar,

       •      Examination of stool specimens for occult blood,

       •      Pregnancy tests, and

       •      Primary culturing for transmittal to a certified laboratory.

If the RHC performs only these six tests, it may obtain a waiver certificate from the regional
Clinical Laboratory Improvement Act (CLIA) office.

If an RHC provides more than the basic lab services on site, it must comply with CLIA
requirements for the lab services actually delivered.

Other Ambulatory Services
Other ambulatory services that may be provided by a RHC include non-primary care services
covered by the Louisiana Medicaid State plan, but not included in the RHC’s core services.
These services may be provided by the RHC if the RHC meets the same standards as other
enrolled providers of those services.




                                           Page 6 of 9                               Section 40.1
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SECTION 40.1: COVERED SERVICES                                                         PAGE(S) 9

Examples of other ambulatory services include, but are not limited to, dental and optometry
services.

Diabetes Self-Management Training
Diabetes self-management training (DSMT) is provided to recipients diagnosed with diabetes.
These services are comprised of one hour of individual instruction and nine hours of group
instruction on diabetes self-management. Recipients shall receive up to ten hours of services during
the first 12-month period beginning with the initial training date. After the first 12-month period
has ended, recipients shall only be eligible for two hours of individual instruction on diabetes self-
management per calendar year.

Encounter
A medical encounter (inclusive of mental health and DSMT services) is defined as a face-to-face
visit with a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse,
clinical psychologist, clinical social worker or any other State plan approved ambulatory
provider during which an RHC core or other ambulatory service is rendered. Multiple medical
encounters with more than one health care practitioner or with the same health care practitioner,
which take place on the same day at a single location, constitute a single visit, except for cases in
which the recipient, subsequent to the first encounter, suffers illness or injury requiring
additional diagnosis or treatment.

A dental encounter is defined as a face-to-face visit with a dentist where dental services are
rendered. Multiple dental encounters with more than one health care practitioner or with the
same health care practitioner, which take place on the same day at a single location, constitute a
single visit except for cases in which the recipient, subsequent to the first encounter, suffers
illness or injury requiring additional diagnosis or treatment.

Service Limits
Only one medical encounter (inclusive of mental health and DSMT services) per day per
recipient and one dental encounter per day may be billed per recipient except in cases in which
the recipient, subsequent to the first encounter, suffers illness or injury requiring additional
diagnosis or treatment. Services shall not be arbitrarily delayed or split in order to bill additional
encounters.

Each RHC medical encounter (inclusive of mental health and DSMT encounters) is counted as 1
of the 12 allowable physician outpatient visits per calendar year for recipients who are 21 years
of age or older. Visits for recipients who are under 21 years of age and for prenatal and
postpartum care are excluded from this service limitation.



                                            Page 7 of 9                                 Section 40.1
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CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.1: COVERED SERVICES                                                     PAGE(S) 9

For Louisiana Medicaid to reimburse outpatient visits beyond the maximum allowed visits per
fiscal year, the physician must request an extension from the fiscal intermediary’s Prior
Authorization (PA) Unit. Extensions will be granted only for emergencies, e.g., trauma, life
threatening conditions and life-sustaining treatments, e.g., chemotherapy for malignant diseases
or radiation therapy.

Separate encounters for DSMT services are not permitted and the delivery of DSMT services
alone does not constitute an encounter visit.

Request for Emergent or Life Threatening Conditions

To request an extension for a visit for emergent or a life threatening condition, providers must
obtain prior approval from the PA Unit. Providers must complete and submit the 158-A form
with medical documentation substantiating the need for additional visits using encounter code
T1015. (See Appendix A for contact information and Appendix B for a copy of form 158-A)

Exclusions
Medicaid policy does not provide for payment of follow-up visits occurring on the same date as a
previously billed visit, consultation, emergency room care or hospital admission date.

Any services “incident to” an encounter are not billable. These include, but are not limited to
the following:

       •      Injections (allergy, antibiotic, steroids, etc.),

       •      Laboratory tests performed on site, Peak Flow and Spirometry, Respiratory Flow
              Volume Loop, EKG testing and interpretation, and x-rays,

       •      Immunizations,

       •      Hearing/Vision screenings, and

       •      Filling and/or obtaining prescriptions.

Service Delivery
Upon presentation at the clinic, a full mental, physical and dental assessment shall be performed
that includes a written plan for each identified problem noted in the history and physical exam.
Any health problems identified must be addressed to the highest degree possible. Encounters for
recipients under the age of 21 must include all the aspects of a well-child screening visit.



                                            Page 8 of 9                             Section 40.1
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CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.1: COVERED SERVICES                                                     PAGE(S) 9

The medical encounter level of service must include at a minimum:

       •       An expanded, problem-focused history (chief complaint, brief history of present
               illness, problem pertinent system review).

       •       An expanded, problem-focused exam (limited exam of the affected body area or
               organ system and other symptomatic or related organ systems).

This would be low level complexity of medical decision making (limited number of diagnoses,
limited complexity of data to review, the risk of complications and management options- low).

A new patient medical encounter level of service is to include the following:

       •       A detailed history (chief complaint, history of present illness, problem pertinent
               system review, pertinent past, family, social history).

       •       A detailed exam with low-to moderate complexity decision making.




                                           Page 9 of 9                              Section 40.1
LOUISIANA MEDICAID PROGRAM                                        ISSUED:                  10/19/12
                                                               REPLACED:                   12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.2: PROVIDER REQUIREMENTS                                                     PAGE(S) 4


                              PROVIDER REQUIREMENTS

Location

An RHC must be located in an area defined by the United States Department of Commerce,
Census Bureau as non-urbanized. The Census Bureau defines a non-urbanized area as an area
outside an urbanized area with a densely settled territory that contains 50,000 or more people.

Shortage Area Designation
A practice is eligible for initial RHC certification if it is located in an area “currently” designated
as a Medically Underserved Area (MUA) or Health Professional Shortage Area (HPSA). The
shortage area designation cannot be more than 3 years old to be considered current.

In order for RHCs to be eligible for HPSA facility designation, the clinic shall:

       •       Not deny requested health care services, and shall not discriminate in the
               provision of services to an individual who is unable to pay for services or whose
               services are paid by the Medicare, Medicaid, or Children’s Health Insurance
               Program,

       •       Prepare a schedule of fees consistent with locally prevailing rates or charges,

       •       Prepare a corresponding schedule of discounts (including waivers) to be applied
               to such fees or payments, with adjustments made on the basis of the patient’s
               ability to pay,

       •       Make every reasonable effort to secure from patients the fees and payments for
               services, and fees should be sufficiently discounted in accordance with the
               established schedule of discounts,

       •       Enter into agreements with the State Medicaid agency to ensure coverage of
               beneficiaries, and

       •       Take reasonable and appropriate steps to collect all payments due for services.

Staffing
An RHC is required to employ a mid-level provider such as a nurse practitioner or physician
assistant at least 50 percent of the time the practice is open to see patients.



                                             Page 1 of 4                                 Section 40.2
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SECTION 40.2: PROVIDER REQUIREMENTS                                                PAGE(S) 4



Medicaid Enrollment Criteria

To be eligible for enrollment in the Louisiana Medicaid Program, the RHC must be an entity:

       •      Receiving certification for participation in the Medicare program,

       •      Receiving licensure/certification from the Department of Health and Hospitals’
              Health Standards Section,

       •      Complying with the Clinical Laboratory Improvement Amendment (CLIA) for all
              laboratory sites.

All practitioners providing patient services must be enrolled with the fiscal intermediary’s (FI)
provider enrollment unit and be linked to the RHC at the time of enrollment in order for the
facility to receive reimbursement.

NOTE: The effective date of enrollment shall not be prior to the date of receipt of a
completed enrollment packet.

Diabetes Self-Management Training
In order to receive Medicaid reimbursement for diabetes self-management training (DSMT)
services, the RHC must have a DSMT program that meets the quality standards of one of the
following accreditation organizations:

       •      The American Diabetes Association,

       •      The American Association of Diabetes Educators, or

       •      The Indian Health Service.

All DSMT programs must adhere to the national standards for diabetes self-management
education. Each member of the instructional team must:

       •      Be a certified diabetes educator (CDE) certified by the National Certification
              Board for Diabetes Educators, or

       •      Have recent didactic and experiential preparation in education and diabetes
              management.



                                           Page 2 of 4                              Section 40.2
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SECTION 40.2: PROVIDER REQUIREMENTS                                                PAGE(S) 4




At a minimum, the instructional team must consist of one of the following professionals who is a
CDE:

       •      A registered dietician,

       •      A registered nurse, or

       •       A pharmacist.

All members of the instructional team must obtain the nationally recommended annual
continuing education hours for diabetes management.

Satellite Clinics
Satellite clinics must enter into a separate provider agreement from the parent center and obtain
its own provider number for billing and reimbursement purposes.

Mobile Clinics
An RHC is prohibited from enrolling a mobile clinic in the Louisiana Medicaid program.
Services rendered at the mobile clinic must be billed using the stationary clinic’s provider
number.

NOTE: All mobile clinics must be HRSA approved facilities.

Out of State RHCs in Trade Areas
An RHC located in the trade areas designated by the Department that wishes to enroll in the
Louisiana Medicaid program, must meet the provider enrollment requirements of an RHC
located in Louisiana and include a letter from the RHCs home state verifying its reimbursement
rate.

Change in Ownership
When there is a change in ownership, Medicaid must be notified within 30 calendar days of the
date of the RHC ownership change. The new owner is required to enter into a new provider
agreement with the Louisiana Medicaid program. Failure to enter into a new provider agreement




                                          Page 3 of 4                               Section 40.2
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SECTION 40.2: PROVIDER REQUIREMENTS                                                 PAGE(S) 4


following a change in ownership will result in the clinic’s termination as a Louisiana Medicaid
provider.

Cost Reports
RHCs are required to file an annual cost report with appropriate addenda within five months of
the clinic’s fiscal year end. Failure to submit cost reports by the due date may result in Medicaid
payments being suspended. (See Appendix A for contact information)

Medicare Certification
RHCs are required to submit proof on an annual basis of Medicare certification as a RHC.
Failure to submit the annual certification may result in disenrollment or payments being
suspended.




                                           Page 4 of 4                               Section 40.2
LOUISIANA MEDICAID PROGRAM                                      ISSUED:                 12/01/10
                                                             REPLACED:                  11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.3: RECORD KEEPING                                                         PAGE(S) 2

                                     RECORD KEEPING
The clinic must maintain all clinical and fiscal records in accordance with written policies and
procedures. The records must readily distinguish one type of service from another that is provided.

A designated member of the professional staff must be responsible for maintaining the records to
ensure that they are complete, accurately documented, readily accessible, and systematically
organized.

For each recipient receiving health care services, the center must maintain a record that includes
the following as applicable:

               Identification and social data, consent forms, pertinent medical history,
               assessment of the health status and health care needs of the recipient, and a brief
               summary of the episode, disposition, and instructions to the recipient.

               Reports of physical examinations, diagnostic and laboratory test results,
               consultative findings, physician’s orders, reports of treatments and medications,
               and other pertinent information necessary to monitor the recipient’s progress, as
               well, as the physician or health care professional’s signature.

Record Maintenance and Availability
The clinic is responsible for the following:

               Maintaining adequate financial and statistical records in the form that contains the
               data required by the Bureau of Health Services Financing (BHSF) and fiscal
               intermediary that supports the payment and distinguishes the type of service
               provided to the recipient.

               Making the records available for verification and audit by BHSF or its contracted
               auditing agent, and

               Maintaining financial data on an accrual basis, unless it is part of a governmental
               institution that uses a cash basis of accounting. In the latter case, depreciation on
               capital assets in accordance with Health Insurance Manual 15 (HIM-15) is
               required. (See Appendix A for information about the HIM-15)




                                               Page 1 of 2                            Section 40.3
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                12/01/10
                                                            REPLACED:                 11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.3: RECORD KEEPING                                                       PAGE(S) 2

Protection of Record Information

The center must maintain the confidentiality of records, provide safeguards against loss,
destruction or unauthorized use, govern removal of records from the center and the conditions
for release of information. The recipient’s written consent must be obtained before the release of
information not authorized by law.

Adequacy of Records
Reimbursement may be suspended if the center does not maintain records that provide an
adequate basis to support payments. The suspension will continue until the center demonstrates
to the satisfaction of the BHSF it does, and will continue to, maintain adequate records.

Retention of Records
Records must be retained for at least five years from the date of service or longer if required by
state statute.




                                           Page 2 of 2                               Section 40.3
LOUISIANA MEDICAID PROGRAM                                       ISSUED:                  08/01/12
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CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                            PAGE(S) 6

                                     REIMBURSEMENT
Rural Health Clinics (RHC) are reimbursed for Medicaid covered services under an all-inclusive
Prospective Payment System (PPS) as specified under Section 1902(bb) of the Social Security
Act.

Rates

Determination of Rate

To determine the baseline rate for RHCs enrolled in Louisiana Medicaid prior to January 1,
2001, each clinic’s 1999 and 2000 allowable costs were taken from the RHC’s filed 1999 and
2000 Medicaid cost reports. These costs were totaled and divided by the total number of
Medicaid patient visits in the cost report years. The baseline calculation included all Medicaid
coverable services provided by the RHC regardless of existing methods of reimbursement for
said services.

For RHCs beginning operation in 2000 and having only a 2000 cost report available for
determining the interim PPS rate, the 2000 allowable cost was divided by the total number of
Medicaid patient visits for 2000. Upon receipt of the 2001 cost report, the rate methodology was
applied using 2000 and 2001 costs and Medicaid patient visits to determine the baseline rate.

Any RHC that begins operation on or after January 1, 2001 and enrolls in Louisiana Medicaid will
have their rates established through comparison of a clinic located in the same area or adjacent area
with a similar case load or in the absence of such clinics, in accordance with the regulations
establishing the baseline PPS rates for RHCs.

Alternative Payment Methodologies

Effective July 1, 2008 any provider-based RHC licensed as part of a small rural hospital as of
July 1, 2007 may elect to be reimbursed at 110% of their cost as reported from their latest filed
cost report.

In accordance with Section 1902(bb)(6) of the Social Security Act, no interim or alternative
payment methodologies will be imposed on an RHC without approval from the entity and must
result in payment to the clinic that is at least equal to the amount required to be paid to the clinic
without the alternative payment methodology.




                                            Page 1 of 6                                 Section 40.4
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                08/01/12
                                                            REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                        PAGE(S) 6

Adjustment of Rate

PPS rates are adjusted effective July 1 of the state fiscal year by the published Medicare
Economic Index (MEI) as prescribed in Section 1902(bb)(3)(A) of the Social Security Act.

PPS rates are adjusted to take into account any change (increase or decrease) in the scope of
services furnished by the RHC. A change in scope is an addition, removal, or relocation of service
sites and the addition or deletion of specialty and non-primary services that were not included in
the base line rate calculation.

The RHC is responsible for notifying the BHSF Program Operations Section, in writing, of
any increases or decreases in the scope. If the change is for the inclusion of an additional
service or deletion of an existing service/site the RHC shall include the following in the
notification:

       •       The current approved organization budget and a budget for the addition or
               deletion of services/sites, and

       •       An assessment of the impact on total visits and Medicaid visits associated with the
               change of scope of services.

A new interim rate will be established based upon the reasonable allowed cost contained in the
budget information. The final PPS rate will be calculated using the first two years of audited
Medicaid cost reports which include the change in scope.

Out of State/Trade Area RHC

An out of state RHC in the trade area will be reimbursed the lesser of the Louisiana state-wide
average or the PPS rate assigned to that RHC in its state’s location.

Notice of Rate Setting

The BHSF Program Operations Section will send written notice to the clinic notifying the clinic
of the reimbursement rate per encounter and the methodology used to establish the rate.

The Program Operations Section or its contracted auditing agency will reconcile the initial PPS
rates for provider based RHCs to the final audited PPS rates and inform the clinic of the rate
determination and any reconciling amounts owed or due to/from the clinic.




                                           Page 2 of 6                               Section 40.4
LOUISIANA MEDICAID PROGRAM                                        ISSUED:            08/01/12
                                                               REPLACED:             12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                        PAGE(S) 6

Appeals

RHCs requesting to appeal the established PPS rate must submit their request in writing (See
Appendix A for contact information).

Cost Report Submission
RHCs are required to file a Medicaid annual cost report with appropriate addenda within five
months of the clinic’s fiscal year end. Failure to submit cost reports by the due date may result
in a suspension of Medicaid payments. (See Appendix A for information on where to send cost
reports)

A written request for an extension on submission of the cost report may be granted if received by
the RHC Program Manager within 30 or more days prior to the due date. No extension will be
granted unless the RHC provides evidence of extenuating circumstances beyond its control that
have caused the report to be submitted late.

Audits

All cost reports are subject to audit, including desk audits and field audits.

Encounter Visits

An RHC provider is limited to reimbursement of one medical (inclusive of mental health
services) encounter and one dental encounter per day, except when a recipient, after the first
encounter, suffers illness or injury requiring additional diagnosis or treatment.

Medicaid reimbursement is limited to medically necessary services that are covered by the
Medicaid State Plan and would be covered if furnished by a physician.

Payment for Adjunct Services

Reimbursement will be made for adjunct services in addition to the encounter rate paid for
professional services when these services are rendered during the evening, weekend or holiday
hours. The reimbursement is a flat fee in addition to the reimbursement for the associated
encounter. Reimbursement is limited to services on weekends, state legal holidays, and between
the hours of 5 p.m. and 8 a.m., Monday through Friday. Documentation must include the time
the services were rendered.

NOTE: Payment is not allowed when the encounter is for dental services only.




                                             Page 3 of 6                            Section 40.4
LOUISIANA MEDICAID PROGRAM                                      ISSUED:                 08/01/12
                                                             REPLACED:                  12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                          PAGE(S) 6

Billing

Medical/Behavioral Encounters

Medical/behavioral health services are reimbursed as encounters. Encounter visits must be billed
on a CMS-1500 using encounter code T1015. The encounter reimbursement includes all
services provided to the recipient on that date of service and any services on a subsequent day
incident to the original encounter visit. In addition to the encounter code, it is necessary to
indicate the specific services provided by entering the individual procedure code, description,
and total charges for each service provided on subsequent lines.

When behavioral health services are the only services provided during an encounter, and they are
administered by a licensed clinical social worker or a clinical psychologist, the RHC provider
identification number must be placed as both the billing and attending provider with the
appropriate modifiers and detail line procedure codes on the claim.

A visit to pick up a prescription or a referral is not considered a billable encounter. Lab or x-ray
services with no “face-to-face” encounter with a covered RHC provider do not constitute an
RHC visit and will not be reimbursed separately as they are part of the original medical
encounter which warranted these additional services.

If a covered service is provided via an interactive audio and video telecommunications system
(telemedicine), it must be identified on the claims form by appending the Health Insurance
Portability and Accountability Act (HIPAA) 1996 complaint modifier “GT” to the appropriate
procedure code.

For obstetrical services, providers must bill the encounter code T1015 with modifier TH and all
services performed on that date of service. When this modifier is used, the visit is not counted in
the 12 office and other outpatient visit limit for recipients 21 years and older.

NOTE: Medical encounter services not covered through the Professional Services Program are
not covered through the RHC Program.

Adjunct Services

RHC adjunct services should be billed with the T1015 encounter code, the appropriate detail
procedure, along with the adjunct service procedure code. The adjunct service procedure code
may not be submitted as the only “detail line” for the encounter. Providers should bill their usual
and customary charges for payment of the adjunct procedure code.




                                            Page 4 of 6                               Section 40.4
LOUISIANA MEDICAID PROGRAM                                      ISSUED:                 08/01/12
                                                             REPLACED:                  12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                          PAGE(S) 6

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screening
Services

EPSDT screening services must be billed using the 837P Professional format using encounter
code T1015 with modifier EP.

It will be necessary to indicate the specific screening services provided by entering the individual
procedure code for each service rendered on the appropriate line. If a registered nurse performs
the screening, the appropriate procedure code must be entered followed by the modifier TD.

If immunizations are given at the time of the screening, then those codes continue to be billed on
the CMS-1500, along with encounter code T1015 and modifier EP. All claims billed using the
T1015 and modifier EP must include supporting detail procedures. Only a physician doing a
screening should bill with no modifier.

Dental Encounters

All dental services must be billed on the 2006 ADA claim form using the encounter code D0999.
It will be necessary for providers to indicate the specific dental services provided by entering the
procedure code for each service rendered on subsequent lines. All claims billed using D0999
must include supporting detail procedures.

The Recipient Eligibility Verification System (REVS) or the Medicaid Eligibility Verification
System (MEVS) should be used to obtain recipient eligibility information. Providers should
keep hardcopy proof of eligibility from MEVS on file. Medicaid eligibility verification is also
available on the web. (See Appendix A for web information)

NOTE: The dental encounter, D0999, may be billed on the same date of services as the
encounter codes T1015, T1015 TH (OB encounter), and/or T1015 EP (EPSDT screening).

Medicare/Medicaid Dual Eligible Billing

Medicaid pays the Medicare co-insurance, up to the Medicaid established encounter rate, for
recipients who are eligible for Medicare and Medicaid. Providers should first file claims with
the regional Medicare fiscal intermediary/carrier, ensuring the recipient’s Medicaid number is
included on the Medicare claim form, before filing with Medicaid.

After the Medicare claim has been processed, then Medicaid should be billed. Providers must
bill these claims on the UB92/UB04 and include the Medicare Explanation of Benefits, a copy of
the Medicare claims and put the Medicaid provider number and Medicaid recipient number in
the appropriate form locators. (See Appendix A for information on where to send the claim)



                                            Page 5 of 6                               Section 40.4
LOUISIANA MEDICAID PROGRAM                                    ISSUED:                08/01/12
                                                           REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
SECTION 40.4: REIMBURSEMENT                                                        PAGE(S) 6

Note: This is the only instance where Louisiana Medicaid may be billed using the UB92/UB04
for RHC services. Straight Medicaid claims must be processed on the CMS-1500 claim form.

Outpatient Services

For all services rendered at the RHC, in a nursing home, or during home visits, the RHC provider
identification number must be used as the billing provider number in the appropriate place on the
CMS 1500 claim form.

Inpatient Services

Physician inpatient services are billed through the physician’s individual provider number as the
billing provider. Physicians are not allowed to bill through their RHC group number for
inpatient services.




                                          Page 6 of 6                               Section 40.4
LOUISIANA MEDICAID PROGRAM                                          ISSUED:                 02/01/11
                                                                  REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX A: CONTACT INFORMATION                                                          PAGE(S) 1

                                 CONTACT INFORMATION

      OFFICE NAME                  TYPE OF ASSISTANCE                 CONTACT INFORMATION
                                                                     Department of Health and Hospitals
                                     Receives annual notice of       Bureau of Health Services Financing
   Department of Health and
                                      Medicare certification                Program Operations
          Hospitals
                                           as an RHC                           P.O. Box 91020
                                                                       Baton Rouge, LA 70821-0546

                                    Receives prior authorization         Molina Medicaid Solutions
   Molina Medicaid Solutions          requests for extension of           Prior Authorization Unit
           PA Unit                 recipient’s maximum allowed                 P.O. Box 14919
                                       annual outpatient visits         Baton Rouge, LA 70898-4919


                                                                          Molina Medicaid Solutions
                                     Provides assistance with
   Molina Medicaid Solutions                                               Provider Relations Unit
                                    questions regarding billing
    Provider Relations Unit                                                   P. O. Box 91024
                                           information
                                                                           Baton Rouge, LA 70821


                                                                         Molina Medicaid Solutions
   Molina Medicaid Solutions       Processes Medicare crossover
                                                                             P. O. Box 91023
    Claims Processing Unit                    claims
                                                                         Baton Rouge, LA 70821



         MEVS/REVS                  Verifies recipient eligibility          www.lamedicaid.com


                                                                       Division of Administrative Law -
                                                                         Health and Hospitals Section
                                                                                P. O. Box 4189
          Division of
                                                                        Baton Rouge, LA 70821-4189
     Administrative Law –            Receives appeal requests
                                                                                (225) 342-0443
  Health and Hospitals Section
                                                                             Fax: (225) 219-9823
                                                                      Phone for oral appeals: (225) 342-
                                                                                     5800

                                                                           Cypress Audit Team
      Cypress Audit Team           Receives annual cost reports        5555 Hilton Avenue, Suite 605
                                                                          Baton Rouge, LA 70808



See http://www.cms.hhs.gov/Manuals/PBM/list.asp for information concerning the Health
Insurance Manual 15 (HIM-15).


                                            Page 1 of 1                                   Appendix A
LOUISIANA MEDICAID PROGRAM               ISSUED:    12/01/10
                                      REPLACED:     11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX B: FORMS                                  PAGE(S) 1

                        FORMS




                        Page 1 of 1                Appendix B
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                12/01/10
                                                            REPLACED:                 11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX C: GLOSSARY                                                               PAGE(S) 3

                                        GLOSSARY

Adjunct Services – Services provided by the RHC on weekends, state legal holidays, and
between the hours of 5 p.m. and 8 a.m. Monday through Friday.

Bureau of Health Services Financing (BHSF) – The Bureau within the Department of Health
and Hospitals responsible for the administration of the Louisiana Medicaid Program.

Change in Scope – a Health Resources Services Administration (HRSA) approved addition,
removal and relocation of service sites and the addition or deletion of specialty and non-primary
services that were not included in the baseline rate calculation.

CMS – The Center for Medicare and Medicaid Services is the Federal agency in DHHS
responsible for administering the Medicaid Program and overseeing and monitoring of the
State’s Medicaid Program.

Department of Health and Hospitals (DHH) – The state agency responsible for administering
the Medicaid Program and health and related services including public health, mental health,
developmental disabilities, and alcohol and substance abuse services. In this manual the use of
the word “department” will mean DHH.

Department of Health and Human Services (DHHS) – The federal agency responsible for
administering the Medicaid Program and public health programs.

Encounter – A face-to-face visit with a physician, physician assistant, nurse practitioner, nurse
midwife, visiting nurse, clinical psychologist, clinical social worker, or any other State plan
approved ambulatory provider during which an RHC core or other ambulatory service is
rendered. Multiple medical encounters with more than one health care practitioner or with the
same health care practitioner, which take place on the same day at a single location, constitute a
single visit, except for cases in which the recipient, subsequent to the first encounter, suffers
illness or injury requiring additional diagnosis or treatment.

Enrollment – A determination made by DHH that a provider agency meets the necessary
requirements to participate as a provider of Medicaid or other DHH-funded services. This is also
referred to as provider enrollment.

Fiscal Intermediary – Is the private fiscal agent with which DHH contracts to operate the
Medicaid Management Information System. It processes Title XIX claims for Medicaid services
provided under the Medicaid Assistance Program, issues appropriate payment and provides
assistance to providers on claims.




                                           Page 1 of 3                              Appendix C
LOUISIANA MEDICAID PROGRAM                                    ISSUED:                12/01/10
                                                           REPLACED:                 11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX C: GLOSSARY                                                               PAGE(S) 3

Health Professional Shortage Area – An urban or rural area, population group, or public or
nonprofit private medical facility which the Secretary of DHHS determines has a shortage of
health professionals.

Health Resources Services Administration – An office within the Department of Health and
Human Services whose mission is to improve access to healthcare services for the uninsured,
isolated, or medically vulnerable through leadership and financial support.

Medicaid – A federal-state financed entitlement program which provides medical services
primarily to low-income individuals under a State Plan approved under Title XIX of the Social
Security Act.

Medically Underserved Area – Areas designated by HRSA as having too few primary care
providers.

Medically Underserved Population – Areas designated by HRSA as having high infant
mortatility, high poverty, and/or high elderly population.

Medicare – The health insurance program for the aged and disabled under Title XVIII of the
Social Security Act.

Medicaid Management Information System (MMIS) – The computerized claims processing
and information retrieval system for the Medicaid Program. This system is an organized method
of payment for claims for all Medicaid covered services. It includes all Medicaid providers and
eligible recipients.

Prospective Payment System (PPS) – Method of reimbursement in which payment is made on
a predetermined, fixed amount. Section 1902(bb) of the Social Security Act describes the
methodology used to determine the PPS for RHCs.

Provider Enrollment – Another term for enrollment.

Rural Health Clinic – an outpatient facility that is primarily engaged in furnishing physicians’
and other medical and health services and that meets other requirements to ensure the health and
safety of individuals served by the clinic. The clinic must be located in a medically underserved
area that is not urbanized as defined by the U.S. Bureau of Census.

Secretary – The Secretary of the Department of Health and Hospitals or any official to whom
(s)he has delegated the pertinent authority.

Satellite Clinics – Separate clinics of the primary RHC.




                                          Page 2 of 3                              Appendix C
LOUISIANA MEDICAID PROGRAM                                    ISSUED:               12/01/10
                                                           REPLACED:                11/01/07
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX C: GLOSSARY                                                              PAGE(S) 3

Service Site – Any place where a health center provides primary health care services to a
geographic service area or population.

Trade Areas – Counties in the states of Texas, Arkansas, and Mississippi that physically share a
border with Louisiana border.




                                          Page 3 of 3                              Appendix C
LOUISIANA MEDICAID PROGRAM                                   ISSUED:             08/01/12
                                                          REPLACED:              12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                    PAGE(S) 30

                                    CLAIMS FILING
This appendix contains the information about the following:

   •   Instructions for billing using the CMS-1500 Claim Form

   •   Example of the CMS-1500 Claim Form

   •   Instructions for adjusting or voiding a CMS-1500 claim using the 213 Adjustment/Void
       Form

   •   Example of 213 Adjustment/Void Form

   •   Instructions for billing using the ADA Dental Claim Form

   •   Example of the ADA Dental Claim Form

   •   Instructions for adjusting or voiding an ADA claim using the 209 Adjustment/Void Form

   •   Example of the 209 Adjustment/Void Form

   •   Instructions for adjusting or voiding an ADA claim using the 210 Adjustment/Void Form

   •   Example of the 210 Adjustment/Void Form




                                         Page 1 of 30                           Appendix D
LOUISIANA MEDICAID PROGRAM                                      ISSUED:                  08/01/12
                                                             REPLACED:                   12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                           PAGE(S) 30

             CMS 1500 (08/05) Billing Instructions for RHC Services
Rural Health Clinic (RHC) services are billed on the CMS-1500 (08/05) claim form or
electronically in the 837P transaction.

Items to be completed are either required or situational.

   •   Required information must be entered in order for the claim to process. Claims
       submitted with missing or invalid information in these fields will be returned unprocessed
       to the provider with a rejection letter listing the reason(s) the claims are being returned or
       will be denied through the system. These claims cannot be processed until corrected and
       resubmitted by the provider.

   •   Situational information may be required (but only in certain circumstances as detailed in
       the instructions that follow).

Claims should be submitted to:

                                   Molina Medicaid Solutions
                                        P.O. Box 91020
                                    Baton Rouge, LA 70821




                                           Page 2 of 30                                Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                     08/01/12
                                                                            REPLACED:                      12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                               PAGE(S) 30

               CMS 1500 (08/05) Billing Instructions for RHC Services
Locator #         Description                                  Instructions                                Alerts
            Medicare / Medicaid /
            Tricare Champus /
                                        Required -- Enter an “X” in the box marked Medicaid
   1        Champva /
                                        (Medicaid #).
            Group Health Plan /
            Feca Blk Lung
                                        Required – Enter the recipient’s 13 digit Medicaid ID
                                        number exactly as it appears when checking recipient
                                        eligibility through MEVS, eMEVS, or REVS.
   1a       Insured’s I.D. Number       NOTE: The recipients’ 13-digit Medicaid ID number must be
                                        used to bill claims. The CCN number from the plastic ID
                                        card is NOT acceptable. The ID number must match the
                                        recipient’s name in Block 2.
                                        Required – Enter the recipient’s last name, first name,
   2        Patient’s Name
                                        middle initial.
            Patient’s Birth Date        Required – Enter the recipient’s date of birth using six (6)
                                        digits (MM DD YY). If there is only one digit in this field,
   3                                    precede that digit with a zero (for example, 01 02 07).
                                        Enter an “X” in the appropriate box to show the sex of the
            Sex
                                        recipient.
                                        Situational – Complete correctly if the recipient has other
   4        Insured’s Name
                                        insurance; otherwise, leave blank.
   5        Patient’s Address           Optional – Print the recipient’s permanent address.
            Patient Relationship to
   6                                    Situational – Complete if appropriate or leave blank.
            Insured
   7        Insured’s Address           Situational – Complete if appropriate or leave blank.
   8        Patient Status              Optional.
   9        Other Insured’s Name        Situational – Complete if appropriate or leave blank.
                                        Situational – If recipient has no other coverage, leave
                                        blank.
                                        If there is other coverage, the state assigned 6-digit TPL
                                        carrier code is required in this block. This code is returned
                                        through MEVS recipient eligibility inquiries as the Network
            Other Insured’s Policy or
   9a                                   Plan Identifier. The MEVS application is located on the
            Group Number
                                        secure portal of the web site, www.lamedicaid.com.. (The
                                        carrier code list can be found at www.lamedicaid.com under
                                        the Forms/Files link)
                                        Make sure the EOB or EOBs from other insurance(s) are
                                        attached to the claim.
            Other Insured’s Date of
   9b       Birth                       Situational – Complete if appropriate or leave blank.
            Sex




                                                    Page 3 of 30                                         Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                         08/01/12
                                                                            REPLACED:                          12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                PAGE(S) 30

Locator #         Description                                  Instructions                                     Alerts
            Employer’s Name or
   9c                                   Situational – Complete if appropriate or leave blank.
            School Name
            Insurance Plan Name or
   9d                                   Situational – Complete if appropriate or leave blank.
            Program Name
            Is Patient’s Condition
   10                                   Situational – Complete if appropriate or leave blank.
            Related To:
            Insured’s Policy Group or
   11                                   Situational – Complete if appropriate or leave blank.
            FECA Number
            Insured’s Date of Birth
  11a                                   Situational – Complete if appropriate or leave blank.
            Sex
            Employer’s Name or
  11b                                   Situational – Complete if appropriate or leave blank.
            School Name
            Insurance Plan Name or
  11c                                   Situational – Complete if appropriate or leave blank.
            Program Name
            Is There Another Health
  11d                                   Situational – Complete if appropriate or leave blank.
            Benefit Plan?
            Patient’s or Authorized
   12       Person’s Signature          Situational – Complete if appropriate or leave blank.
            (Release of Records)
            Patient’s or Authorized
   13       Person’s Signature          Situational – Obtain signature if appropriate or leave blank.
            (Payment)
            Date of Current Illness /
   14                                   Optional.
            Injury / Pregnancy
            If Patient Has Had Same
   15       or Similar Illness Give     Optional.
            First Date
            Dates Patient Unable to
   16       Work in Current             Optional.
            Occupation
            Name of Referring
   17                                   Situational – Complete if applicable.
            Provider or Other Source
                                                                                                        If the claim date of
                                                                                                        service is prior to the
                                                                                                        elimination of the
                                                                                                        CommunityCARE
                                                                                                        Program and it is
  17a       Unlabelled                  Optional.                                                       applicable, the PCP’s
                                                                                                        7-digit referral
                                                                                                        authorization number
                                                                                                        must be entered in
                                                                                                        block 17a.

  17b       NPI                         Optional.




                                                    Page 4 of 30                                             Appendix D
LOUISIANA MEDICAID PROGRAM                                                   ISSUED:                       08/01/12
                                                                          REPLACED:                        12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                            PAGE(S) 30

Locator #         Description                                Instructions                                  Alerts
            Hospitalization Dates
   18       Related to Current       Optional.
            Services
                                                                                                    Usage to be
   19       Reserved for Local Use   Reserved for future use. Do not use.
                                                                                                    determined.
   20       Outside Lab?             Optional.
            Diagnosis or Nature of   Required -- Enter the most current ICD-9 numeric
   21
            Illness or Injury        diagnosis code and, if desired, narrative description.
            Medicaid Resubmission
   22                                Optional.
            Code
                                     Situational – Complete if appropriate or leave blank.
            Prior Authorization
   23                                If the services being billed must be Prior Authorized, the 9
            Number
                                     digit numeric PA number is required to be entered.
                                     Situational – Applies to the detail lines for drugs and
                                     biologicals only.
                                     CURRENTLY, THIS IS NOT A REQUIREMENT FOR RHC
                                                                                                    CURRENTLY, RHC
                                     PROVIDERS.
                                                                                                    PROVIDERS ARE
                                     In addition to the procedure code, the National Drug Code      NOT REQUIRED TO
                                     (NDC) is required by the Deficit Reduction Act of 2005 for     ENTER THIS
                                     physician-administered drugs and shall be entered in           INFORMATION.
                                     the shaded section of 24A through 24G. Claims for these
                                     drugs shall include the NDC from the label of the
                                     product administered.
                                     To report additional information related to HCPCS codes
                                                                                                    Physicians and other
                                     billed in 24D, physicians and other providers who administer
                                                                                                    provider types who
                                     drugs and biologicals must enter the Qualifier N4 followed
                                                                                                    administer drugs and
            Supplemental             by the NDC. Do not enter a space between the qualifier
   24                                                                                               biologicals must
            Information              and the NDC. Do not enter hyphens or spaces within the
                                                                                                    enter this new drug-
                                     NDC.
                                                                                                    related information in
                                     Providers should then leave one space then enter the           the SHADED section
                                     appropriate Unit Qualifier (see below) and the actual units    of 24A – 24G of
                                     administered. Leave three spaces and then enter the            appropriate detail
                                     brand name as the written description of the drug              lines only.
                                     administered in the remaining space.

                                     The following qualifiers are to be used when reporting NDC     This information must
                                     units:                                                         be entered in addition
                                                                                                    to the procedure
                                        F2   International Unit                                     code(s).
                                        ML   Milliliter
                                        GR   Gram
                                        UN   Unit




                                                 Page 5 of 30                                           Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                         08/01/12
                                                                            REPLACED:                          12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                PAGE(S) 30

Locator #         Description                                  Instructions                                     Alerts
                                        Required -- Enter the date of service for each procedure.
  24A       Date(s) of Service          Either six-digit (MM DD YY) or eight-digit (MM DD YYYY)
                                        format is acceptable.
                                        Required -- Enter the appropriate place of service code for
  24B       Place of Service
                                        the services rendered.
                                                                                                        This indicator was
  24C       EMG                         Situational – Complete if appropriate or leave blank.           formerly entered in
                                                                                                        block 24I.
                                        Required -- Enter the procedure code(s) for services            Enter the appropriate
                                        rendered in the un-shaded area(s).                              encounter procedure
                                                                                                        on the first line.
                                        Encounter Codes:
                                         • RHC encounter visit: T1015
                                                                                                        If both the encounter
            Procedures, Services, or     • RHC obstetrical service: T1015 w/TH modifier.
  24D                                                                                                   code and the detail
            Supplies                     • RHC EPSDT service: T1015 w/EP modifier.
                                                                                                        line(s) are not
                                        In addition to the encounter code, it is necessary to           present, the claim will
                                        indicate on subsequent lines the specific services              deny.
                                        provided by entering the individual procedure code and
                                        description for each service rendered.
                                        Required – Indicate the most appropriate diagnosis for
                                        each procedure by entering the appropriate reference
  24E       Diagnosis Pointer           number (“1”, “2”, etc.) in this block.
                                        More than one diagnosis/reference number may be related
                                        to a single procedure code.
                                        Required -- Enter usual and customary charges for the
  24F       $Charges
                                        service rendered.
                                        Required -- Enter the number of units billed for the
  24G       Days or Units
                                        procedure code entered on the same line in 24D
                                        Situational – Leave blank or enter a “Y” if services were
  24H       EPSDT Family Plan
                                        performed as a result of an EPSDT referral.
                                                                                                        The revised form
                                        Optional. If possible, leave blank for Louisiana Medicaid
   24I      I.D. Qual.                                                                                  accommodates the
                                        billing.
                                                                                                        entry of I.D. Qual.
                                        Situational – If appropriate, entering the Rendering
                                        Provider’s Medicaid Provider Number in the shaded portion
  24J       Rendering Provider I.D. #   of the block is required.
                                        Entering the Rendering Provider’s NPI in the non-shaded
                                        portion of the block is optional at this time.
   25       Federal Tax I.D. Number     Optional.
                                        Situational – Enter the provider specific identifier assigned
                                        to the recipient. This number will appear on the Remittance
   26       Patient’s Account No.
                                        Advice (RA). It may consist of letters and/or numbers and
                                        may be a maximum of 20 characters.




                                                    Page 6 of 30                                             Appendix D
LOUISIANA MEDICAID PROGRAM                                                        ISSUED:                      08/01/12
                                                                               REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                PAGE(S) 30

Locator #         Description                                    Instructions                                   Alerts
                                        Optional. Claim filing acknowledges acceptance of
   27       Accept Assignment?
                                        Medicaid assignment.
   28       Total Charge                Required – Enter the total of all charges listed on the claim.
                                        Situational – If TPL applies and block 9A is completed,
                                        enter the amount paid by the primary payor.
   29       Amount Paid
                                        Enter ‘0’ if the third party did not pay.
                                        If TPL does not apply to the claim, leave blank.
                                        Situational – Enter the amount due after third party
   30       Balance Due                 payment has been subtracted from the billed charges if
                                        payment has been made by a third party insurer.
            Signature of Physician or
            Supplier Including          Optional.
   31       Degrees or Credentials

            Date                        Optional.
            Service Facility Location
   32                                   Situational – Complete as appropriate or leave blank.
            Information
                                                                                                         The revised form
                                                                                                         accommodates entry
  32a       NPI                         Optional.
                                                                                                         of the Service
                                                                                                         Location NPI.
                                        Situational – Complete if appropriate or leave blank.
                                        If site numbers are applicable, the provider must enter the
  32b       Unlabelled                  Qualifier LU followed by the three digit site number. Do
                                        not enter a space between the qualifier and site number
                                        (example “LU001”).
            Billing Provider Info &     Required -- Enter the provider name, address including zip
   33       Ph #                        code and telephone number.
  33a       NPI                         Optional – Enter the billing provider’s NPI number.

                                                                                                         Format change with
                                        Required – Enter the billing provider’s 7-digit Medicaid ID      addition of 33a and
  33b       Unlabelled
                                        number.                                                          33b for provider
                                                                                                         numbers.




                                                     Page 7 of 30                                            Appendix D
LOUISIANA MEDICAID PROGRAM                                            ISSUED:                      08/01/12
                                                                   REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                     PAGE(S) 30

Example of CMS-1500 Claim Form




            X                                                      5632147896325
   Betsey Ross                              01 05 10           X




   TPL carrier code if applicable




    149 0

                                                                   Prior auth # if applicable

                                                                                              1236548
  01 10 12      01 10 12 72         T1015                      1     145 00     1             1236549875
                                                                                              1236548
  01 10 12 01     10 12 72          99213                      1       0 00     1             1236549875




                                                                       145 00                     145 00
                                                                   Always Open RHC
                                                                   123 Main St.
   Ima Biller        2/1/12                                        Any Town, LA 700000
                                                                   1326547895       1234567




                                                Page 8 of 30                                     Appendix D
LOUISIANA MEDICAID PROGRAM                                    ISSUED:                08/01/12
                                                           REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                        PAGE(S) 30

                                 Adjustments and Voids

Completing the 213 Adjustment/Void Form

The 213 adjustment/void form is used to adjust or void incorrect payments on the CMS-1500.
These forms may be obtained from Molina Medicaid Solutions by calling Provider Relations at
(800) 473-2783 or at www.lamedicaid.com using the Forms/Files/User Guides link. Instructions
and an example of a completed 213 adjustment form are shown on the following pages.

If a claim has been paid using the 837P claim transaction, an adjustment or void may be
submitted electronically or by using the Molina 213 adjustment/void form.

Only one claim line can be adjusted or voided on each adjustment/void form.

Only a paid claim can be adjusted or voided. Denied claims must be corrected and resubmitted –
not adjusted or voided.

Only the paid claim's most recently approved control number can be adjusted or voided. For
example:

   1. A claim is approved on the remittance advice dated 07/17/2010, ICN 0198156789000.

   2. The claim is adjusted on the remittance advice dated 12/11/2010, ICN 0345126742100

   3. If the claim requires further adjustment or needs to be voided, the most recently approved
      Control number (0345126742100) and RA date (12/11/2010) must be used.

Claims paid to an incorrect provider number or for the wrong Medicaid recipient cannot be
adjusted. They must be voided and corrected claims submitted.

To file an adjustment, the provider should complete the adjustment as it appears on the original
claim form, changing the item that was in error to show the way the claim should have been
billed. The approved adjustment will replace the approved original and will be listed under the
"adjustment" column on the RA. The original payment will be taken back on the same RA in the
"previously paid" column. An example of an adjustment appears within this document.

To file a void, the provider must enter all the information from the original claim exactly as it
appeared on the original claim. When the void claim is approved, it will be listed under the
"void" column of the RA and a corrected claim may be submitted (if applicable).




                                          Page 9 of 30                             Appendix D
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                08/01/12
                                                            REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                        PAGE(S) 30

Filing Adjustments for a Medicare/Medicaid Claim

When a provider has filed a claim with Medicare, Medicare reimburses the claim, and the claim
becomes a “crossover” to Medicaid for consideration of payment of the Medicare deductible
and/or co-insurance/co-payment.

If, at a later date, it is determined that Medicare has overpaid or underpaid, the provider should
re-bill Medicare for a corrected payment. If these adjustments do not “crossover” from Medicare
to Medicaid, the provider must submit the adjustment hard copy.

In these cases, it is necessary for the provider to file a hard copy adjustment claim (Molina Form
213) with Medicaid. These should be sent with a copy of the most recent Medicare explanation
of benefits and the original explanation of benefits attached to:

                                 Molina Medicaid Solutions
                              Attention: Crossover Adjustments
                                       P.O. Box 91023
                                   Baton Rouge, LA 70821

In addition, the provider should write “2X7” at the top of the adjustment/void form to indicate
the adjustment is for a Medicare/Medicaid claim.




                                         Page 10 of 30                              Appendix D
LOUISIANA MEDICAID PROGRAM                                    ISSUED:                   08/01/12
                                                           REPLACED:                    12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                         PAGE(S) 30

           Instructions for Completing the 213 Adjustment/Void Form

1.    REQUIRED ADJ/VOID—Check the appropriate block

2.    REQUIRED Patient’s Name

      a.     Adjust – Print the name exactly as it appears on the original claim if not adjusting
             this information.

      b.     Void – Print the name exactly as it appears on the original claim.

3.    REQUIRED Patient’s Date of Birth

      a.     Adjust – Print the date exactly as it appears on the original claim if not adjusting
             this information.

      b.     Void – Print the name exactly as it appears on the original claim.

4.    REQUIRED Medicaid ID Number – Enter the 13 digit recipient ID number.

5.    Patient’s Address and Telephone Number

      a.     Adjust – Print the address exactly as it appears on the original claim.

      b.     Void – Print the address exactly as it appears on the original claim.

6.    REQUIRED Patient’s Sex

      a.     Adjust – Print this information exactly as it appears on the original claim if not
             adjusting this information.

      b.     Void – Print this information exactly as it appears on the original claim.

7.    Insured’s Name – Leave blank.

8.    Patient’s Relationship to Insured – Leave blank.

9.    Insured’s Group No. – Complete if appropriate or blank.

10.   Other Health Insurance Coverage – Complete with 6-digit TPL carrier code if appropriate
      or leave blank.



                                        Page 11 of 30                                  Appendix D
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                08/01/12
                                                            REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                          PAGE(S) 30

11.    Was Condition Related to – Leave blank.

12.    Insured’s Address – Leave blank.

13.    Date of – Leave blank.

14.    Date First Consulted You for This Condition – Leave blank.

15.    Has Patient Ever had Same or Similar Symptoms – Leave blank.

16.    Date Patient Able to Return to Work – Leave blank.

17.    Dates of Total Disability-Dates of Partial Disability – Leave blank.

18.    Name of Referring Physician or Other Source – Leave blank.

18a.   Referring ID Number – Leave blank.

19.    For Services Related to Hospitalization Give Hospitalization Dates – Leave blank

20.    Name/Address of Facility Where Services Rendered (if other than home or office) –
       Leave blank.

21.    Was Laboratory Work Performed Outside of Office – Leave blank.

22.    REQUIRED Diagnosis of Nature of Illness

       a.     Adjust – Print the information exactly as it appears on the original claim if not
              adjusting the information.

       b.     Void – Print the information exactly as it appears on the original claim.

23.    Attending Number – Leave this space blank.

24.    Prior Authorization # - Enter the PA number if applicable or leave blank.

25.    REQUIRED A through F

       a.     Adjust – Print the information exactly as it appears on the original claim if not
              adjusting the information.

       b.     Void – Print the information exactly as it appears on the original claim.



                                          Page 12 of 30                              Appendix D
LOUISIANA MEDICAID PROGRAM                                  ISSUED:                08/01/12
                                                         REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                     PAGE(S) 30

26.   REQUIRED Control Number – Print the correct Control Number as shown on the
      remittance advice.

27.   REQUIRED Date of remittance advice that Listed Claim was Paid – Enter MM DD YY
      from RA form.

28.   REQUIRED Reasons for Adjustment – Check the appropriate box if applicable, and
      write a brief narrative that describes why this adjustment is necessary.

29.   REQUIRED Reasons for Void – Check the appropriate box if applicable, and write a
      brief narrative that describes why this void is necessary.

30.   Leave blank.

31.   REQUIRED Physician’s or Supplier’s Name, Address, Zip Code and Telephone
      Number – Enter the requested information appropriately plus the seven (7) digit Medicaid
      provider number. The form will be returned if this information is not entered.

32.   Patient’s Account Number – Enter the patient’s provider-assigned account number.

              REQUIRED items must be completed or form will be returned.




                                       Page 13 of 30                             Appendix D
LOUISIANA MEDICAID PROGRAM                                             ISSUED:                    08/01/12
                                                                    REPLACED:                     12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                 PAGE(S) 30

Example of 213 Adjustment Form




   X

   Adalam, Mary                                 06/11/89                  1234567891234




   060606




    V222
                                                                              1234567




   04   16   12   04   16 12    72     T1015                        1       145.00 1      45.00


    2076156789501                                                       05/01/12

   X                                       Private insurance paid




                                                       Always Open RHC
                                                       123 Smiley St.
   Ima Biller                  6/01/2012               Sunny, LA 70000
                                                       NPI #1234567897 Provider# 9999999




                                               Page 14 of 30                                 Appendix D
LOUISIANA MEDICAID PROGRAM                                     ISSUED:                08/01/12
                                                            REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                        PAGE(S) 30

             ADA Claim Form Billing Instructions for RHC Services

Medicaid EPSDT Dental, EDSPW and Adult Denture Program Services
The 2006 American Dental Association Claim Form is the only hardcopy dental claim form
accepted for Medicaid reimbursement of services provided under the Medicaid EPSDT Dental
Program, EDSPW Program or Adult Denture Program. These claim forms may be obtained by
contacting the American Dental Association or your dental supply company.

The following billing instructions correspond to the 2006 ADA Claim Form.

Required information must be entered to ensure claims processing.

Situational information may be required only in certain situations as detailed in each instruction
item.

Information on the claim form may be handwritten or computer generated and must be legible
and completely contained in the designated area of the claim form.

EPSDT Dental Program, EDSPW Program and Adult Denture Program claims should be
submitted to:

                                   Molina Medicaid Solutions
                                       P. O. Box 91022
                                    Baton Rouge, LA 70821




                                         Page 15 of 30                              Appendix D
LOUISIANA MEDICAID PROGRAM                                                      ISSUED:                         08/01/12
                                                                             REPLACED:                          12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                 PAGE(S) 30

              ADA Claim Form Billing Instructions for RHC Services

Locator #         Description                                    Instructions                                    Alerts
                                                                                                          If a claim is being
                                                                                                          submitted for
                                         Required -- Check applicable box to designate whether the        payment, you must
                                         claim is a statement of actual services or a request for prior   mark “Statement of
                                         authorization.                                                   Actual Services” in
                                                                                                          Block 1 of the claim
    1       Type of Transaction          Situational – Check box marked “EPSDT Title XIX” if              form.
                                         patient is Medicaid eligible and under 21 years of age.          Claims for payment
                                                                                                          that are sent to
                                         If block is not checked, the claim will be processed as an       Molina Medicaid
                                         adult claim.                                                     Solutions should
                                                                                                          never include
                                                                                                          radiographs.
                                         Situational – Enter the prior authorization number assigned
            Predetermination /
    2                                    by Medicaid when submitting a claim for services that
            Preauthorization Number
                                         require prior authorization.
            Company / Plan Name,
                                         Situational – Enter the primary payer information if
    3       Address, City, State, Zip
                                         applicable.
            Code
            Other Dental or Medical
    4                                    Situational – If yes, complete Block 9.
            Coverage?
            Name of
            Policyholder/Subscriber
    5                                    Situational.
            in #4 (Last, First, Middle
            Initial, Suffix)
            Date of Birth
    6                                    Situational.
            (MM/DD/CCYY)
    7       Gender                       Situational.
            Policyholder/Subscriber
    8                                    Situational.
            ID
                                         Situational –
                                         If there is other coverage, the state assigned 6-digit TPL
                                         carrier code is required in this block. This code is returned
                                         through MEVS recipient eligibility inquiries as the Network
                                         Plan Identifier. The MEVS application is located on the
    9       Plan/Group Number            secure portal of the web site, www.lamedicaid.com.. (The
                                         carrier code list can be found at www.lamedicaid.com under
                                         the Forms/Files link)

                                         If the provider has chosen to bill the third party and
                                         Medicaid, an explanation of benefits must be attached to
                                         the claim filed with Medicaid.




                                                   Page 16 of 30                                             Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                      08/01/12
                                                                            REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                PAGE(S) 30

Locator #         Description                                   Instructions                                Alerts
            Patient’s Relationship to
   10                                   Situational.
            Person Named in #5
            Other Insurance
            Company / Dental
   11       Benefit Plan Name,          Situational.
            Address, City, State, Zip
            Code
            Policyholder/Subscriber     Required -- Enter the recipient’s last name, first name, and
            Name (Last, First, Middle   middle initial exactly as verified through REVS or MEVS.
   12
            Initial, Suffix) Address,
            City, State, Zip Code       Recipient’s address is optional.
                                        Required -- Enter the recipient’s eight-digit date of birth in
            Date of Birth
   13                                   month, day, and year (MM/DD/CCYY). If there is only one
            (MM/DD/CCYY)
                                        digit in a field, precede that digit with a zero.
   14       Gender                      Optional – Check appropriate block.
                                        Required -- Enter the thirteen-digit Medicaid ID number as
            Policyholder/Subscriber     obtained from REVS or MEVS.
   15
            ID                          Do not use the sixteen-digit Card Control Number (CCN)
                                        from the recipient’s Medicaid card.
   16       Plan / Group Number         Situational.
   17       Employer Name               Situational.
            Relationship to
   18       Policyholder/Subscriber     Situational.
            in #12 above.
   19       Student Status              Situational.
                                        Situational. This field should be used only when other
            Name (Last, First, Middle   private insurance is primary.
   20       Initial, Suffix) Address,
            City, State, Zip Code       Note: The Medicaid recipient’s name is required to be
                                        entered in Block 12.
            Date of Birth
   21                                   Situational.
            (MM/DD/CCYY)
   22       Gender                      Situational.
                                        Optional – Enter a Patient ID/Account Number if one has
                                        been assigned by the dentist. If entered, this identifier will
            Patient ID / Account #      appear on the Remittance Advice.
   23
            (Assigned by Dentist)       The Patient ID/Account Number may consist of letters
                                        and/or numbers, and it may be a maximum of 20
                                        characters.
                                        Required -- Enter the date the service was performed in
                                        month, day, and year (MM/DD/CCYY). If there is only one
            Procedure Date              digit in a field, precede that digit with a zero.
   24
            (MM/DD/CCYY)
                                        A service must have been performed/delivered before billing
                                        Medicaid for payment.




                                                   Page 17 of 30                                          Appendix D
LOUISIANA MEDICAID PROGRAM                                              ISSUED:                        08/01/12
                                                                     REPLACED:                         12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                        PAGE(S) 30

Locator #         Description                            Instructions                                   Alerts
                                                                                                 Only one tooth
                                                                                                 number/letter or oral
                                                                                                 cavity designator is
                                                                                                 allowed per claim
                                  Situational – Enter the oral cavity designator when
                                                                                                 line. Refer to the
                                  applicable for a specific procedure. Refer to the Dental
                                                                                                 applicable dental
                                  Services Manual, Dental Fee Schedule for specific
                                                                                                 program policy
   25       Area of Oral Cavity   requirements regarding oral cavity designator.
                                                                                                 and/or dental
                                                                                                 program fee
                                  If an oral cavity designator is required by Medicaid, do not
                                                                                                 schedule for specific
                                  enter a tooth number or letter in Block 27.
                                                                                                 requirements
                                                                                                 regarding tooth
                                                                                                 number/letter or oral
                                                                                                 cavity designator.
   26       Tooth System          Leave Blank
                                                                                                 Only one tooth
                                                                                                 number/letter or oral
                                                                                                 cavity designator is
                                                                                                 allowed per claim
                                  Situational – Enter a tooth number or letter when
                                                                                                 line. Refer to the
                                  applicable for a specific procedure. Refer to the Dental
                                                                                                 applicable dental
                                  Services Manual, Dental Fee Schedule for specific
            Tooth Number(s) or                                                                   program policy
   27                             requirements regarding tooth number or letter.
            Letter(s)                                                                            and/or dental
                                                                                                 program fee
                                  If a tooth number or letter is required by Medicaid, do not
                                                                                                 schedule for specific
                                  enter an oral cavity designator in Block 25.
                                                                                                 requirements
                                                                                                 regarding tooth
                                                                                                 number/letter or oral
                                                                                                 cavity designator.
                                  Situational – Enter tooth surface(s) when procedure code
                                  reported directly involves one or more tooth surfaces. Enter
                                  up to five of the following codes:
                                     B = Buccal
                                     D = Distal
                                     F = Facial
   28       Tooth Surface            I = Incisal
                                     L = Lingual
                                     M = Mesial, and
                                     O = Occlusal
                                  Duplicate surfaces are not payable on the same tooth for
                                  most services. Refer to the Dental Services Manual for
                                  more information.




                                            Page 18 of 30                                           Appendix D
LOUISIANA MEDICAID PROGRAM                                                ISSUED:                         08/01/12
                                                                       REPLACED:                          12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                           PAGE(S) 30

Locator #         Description                               Instructions                                   Alerts
                                                                                                    REMINDER: The
                                                                                                    all inclusive
                                                                                                    encounter code
                                                                                                    (D0999) must be
                                                                                                    entered on the 1st
                                                                                                    line of the claim
                                                                                                    form. Tooth
                                                                                                    number/letter,
                                                                                                    surface or oral
                                                                                                    cavity designator is
                                                                                                    not required for this
                                    Required – Enter the all-inclusive encounter code (D0999)
                                                                                                    line. In addition to
                                    on the first line then enter the appropriate dental procedure
                                                                                                    the encounter
                                    codes from the current version of Code on Dental
   29       Procedure Code                                                                          information, it is
                                    Procedures and Nomenclature. The Medicaid reimbursable
                                                                                                    necessary to
                                    codes are located in the Medicaid Dental Services Manual,
                                                                                                    indicate on
                                    Dental Fee Schedule.
                                                                                                    subsequent lines of
                                                                                                    the claim form, the
                                                                                                    specific dental
                                                                                                    services provided
                                                                                                    by entering the
                                                                                                    individual
                                                                                                    procedures,
                                                                                                    including all
                                                                                                    appropriate line item
                                                                                                    information for each
                                                                                                    service rendered.
   30       Description             Required – Enter the description of the service performed.
                                    Required -- Enter the dentist’s full (usual and customary)
   31       Fee
                                    fee for the dental procedure reported.
   32       Other Fee(s)            Leave Blank

   33       Total Fee               Required – Total of all fees listed on the claim form.

                                    Situational – Complete if applicable.
                                    Report missing teeth on each claim submission. Indicate all
                                    missing teeth with an “X”. Indicate teeth to be extracted
                                    with an “/”.
            (Place an ‘X’ on each   In the following circumstances, this information is required:
   34
            missing tooth)
                                    If the claim is for the Adult Denture Program.
                                    If the claim is for the EPSDT Dental Program when
                                    requesting a prosthetic, space maintainer or root canal
                                    therapy.




                                              Page 19 of 30                                            Appendix D
LOUISIANA MEDICAID PROGRAM                                              ISSUED:                       08/01/12
                                                                     REPLACED:                        12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                          PAGE(S) 30

Locator #         Description                             Instructions                                Alerts
                                   Situational – Enter the amount paid by the primary payor if
                                   block 9 is completed.
                                   Write the words “Carrier Paid” and the amount that was paid
                                   by the carrier (including zero [$0] payment) in this block.
                                   Enter any additional information required by Medicaid
                                   regarding requested services (including description of the
                                   patient management techniques used for which a patient
                                   management fee is billed; reason for hospitalization
                                   requests, or any additional information that the provider
   35       Remarks                needs to include).
                                   For prior authorization requests, if the information required
                                   in the remarks section of the claim form exceeds the space
                                   available, the provider should include a cover sheet
                                   outlining the information required to document the
                                   requested services. If a cover sheet is used, please be sure
                                   it includes the date of the request, the recipient’s name and
                                   Medicaid ID # and the provider’s name and Medicaid ID #.
                                   A copy of this cover sheet, along with a copy of the request
                                   for prior authorization, should be kept in the patient’s
                                   treatment record.
   36       Authorizations         Optional.
   37       Authorizations         Optional.
                                   Situational – Check the applicable box if services are to be
                                   or were provided at a location other than the address
                                   entered in Block 48.
   38       Place of Treatment
                                   If services were provided at a location other than the
                                   address entered in Block 48, completion of this block and
                                   Block 56 is required.
                                   Situational – Enter 00 to 99 in applicable boxes.

                                   Claims submitted for prior authorization are required to
   39       Number of Enclosures   contain the identified attachments.

                                   Claims submitted for payment should not contain any of the
                                   attachments listed in Block 39.
                                   Situational – Complete if applicable.

                                   Claims requesting comprehensive orthodontic services are
            Is Treatment for
   40                              required to enter information in this block.
            Orthodontics?
                                   Refer to the Dental Services Manual for guidelines
                                   regarding comprehensive orthodontic services.




                                               Page 20 of 30                                        Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                      08/01/12
                                                                            REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                PAGE(S) 30

Locator #         Description                                   Instructions                                Alerts
   41       Date Appliance Placed       Situational.
            Months of Treatment
   42                                   Situational.
            Remaining.
            Replacement of              Situational – Check appropriate box if applicable; if
   43
            Prosthesis                  checked, complete Block 44 if known.
                                        Situational – If Block 43 is checked and if known, enter the
   44       Date Prior Placement        appropriate eight-digit date in month, day and year
                                        (MM/DD/CCYY).

                                        Situational – If the claim is the result of Occupational
   45       Treatment Resulting from    Illness / Injury, Auto Accident, or Other Accident, then this
                                        Block is required. Check the appropriate box.
                                        Situational. If Block 45 is completed, then this block is
            Date of Accident
   46                                   required. Enter the eight-digit date in month, day and year
            (MM/DD/CCYY).
                                        (MM/DD/CCYY).
                                        Situational. If Auto Accident is checked in Block 45, this
   47       Auto Accident State         block is required. Enter the state in which the auto
                                        accident occurred.

                                        Required. Enter the name of the individual dentist if the
                                        payment is being made to an individual dentist. Enter the
            Billing Dentist Name,
                                        group name if the payment is being made to a dental group.
   48       Address, City, State, Zip
            Code
                                        Enter the full address, including city, state and zip code, of
                                        the dentist or dental group to whom payment is being made.

   49       NPI                         Optional – Enter the billing provider’s 10-digit NPI number.

   50       License Number              Optional.

   51       SSN or TIN                  Optional.

                                        Required -- Enter the phone number for the billing dental
   52       Phone Number
                                        provider.
                                        Required – Enter the 7-digit Medicaid Provider ID of the
  52A       Additional Provider ID
                                        billing dental provider.

   53       Signature                   Optional.
                                        Optional – Enter the 10-digit NPI of the treating (attending)
   54       NPI
                                        dental provider
                                        Required – Enter the license number of the treating
   55       License Number
                                        (attending) dental provider.




                                                    Page 21 of 30                                         Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                       08/01/12
                                                                            REPLACED:                        12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                 PAGE(S) 30

Locator #         Description                                   Instructions                                 Alerts
                                        Situational – Enter the full address, including city, state and
            Address, City, State, Zip
   56                                   zip code, where treatment was performed by treating
            Code
                                        (attending) dental provider, if different from Block 48.

  56A       Provider Specialty Code     Optional.

   57       Signature                   Optional.
                                        Optional – Enter the 10-digit NPI of the treating (attending)
   58       NPI
                                        dental provider




                                                    Page 22 of 30                                          Appendix D
LOUISIANA MEDICAID PROGRAM                     ISSUED:      08/01/12
                                            REPLACED:       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                PAGE(S) 30

Example of ADA Claim Form




                            Page 23 of 30                 Appendix D
LOUISIANA MEDICAID PROGRAM                                   ISSUED:                08/01/12
                                                          REPLACED:                 12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                      PAGE(S) 30

                EPSDT Dental Services Adjustment/Void (209) and
                Adult Dental Services Adjustment/Void (210) Form
The EPSDT Dental Services 209 Adjustment/Void form (revision date 10/04) must be used
when submitting adjustments/voids for EPSDT Dental Program services for all dates of service.

Additionally, when submitting adjustments/voids for the Adult Denture Program or Expanded
Dental Services for Pregnant Women Program for all dates of service, dental providers must use
the Adult Dental Services 210 Adjustment/Void form (revision date 10/04).

For both adjustment/void forms, the Form Locator 15 has been renamed as “Patient
I.D./Account# Assigned by Dentist”. If the patient’s account (medical record) number is entered
here, it will appear on the Medicaid Remittance Advice. It may consist of letters and/or
numbers, and it may be a maximum of 20 positions.

Providers can obtain these forms from Molina Medicaid Solutions or through the Louisiana
Medicaid website at www.lamedicaid.com. Instructions for completing the forms can also be
obtained on the Medicaid website or within this document.




                                        Page 24 of 30                             Appendix D
LOUISIANA MEDICAID PROGRAM                                                   ISSUED:                      08/01/12
                                                                          REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                              PAGE(S) 30

         Instructions for Completing 209 Adjustment/Void Form (EPSDT)

Locator #         Description                                  Instructions                               Alerts
   1        Adj/Void                    Check the appropriate box.
                                        Adjust - Enter the information exactly as it appeared on the
   2        Patient's Last Name First
                                        original invoice
   3        Name
                                        Void - Enter the information exactly as it appeared on the
   4        MI
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice. If you wish to change this number, you
            Medical Assistance ID
   5                                    must first void the original claim.
            Number
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice.
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   6        Patient's Address
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   7        Date of Birth
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   8        Sex
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
  9-14                                  Not Required
                                        Adjust – Enter the information exactly as it appeared on the
            Patient ID/Account
                                        original invoice
   15       Number (Assigned By
                                        Void – Enter the information exactly as it appeared on the
            Dentist)
                                        original invoice
                                        Adjust – Enter the information exactly as it appeared on the
                                        original invoice
   16       Pay to Dentist or Group
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice. If you wish to change this number, you
            Pay to Dentist or Group
   17                                   must first void the original claim.
            Provider No.
                                        Void – Enter the information exactly as it appeared on the
                                        original invoice
   18       Are X-Rays Enclosed         Not required
                                        Adjust - Enter the information exactly as it appeared on the
            Treatment Necessitated      original invoice.
   19
            By                          Void - Enter the information exactly as it appeared on the
                                        original invoice.




                                                  Page 25 of 30                                         Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                       08/01/12
                                                                            REPLACED:                        12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                 PAGE(S) 30

 Locator #         Description                                   Instructions                                Alerts
                                         Adjust - Enter the information exactly as it appeared on the
                                         original invoice unless the information is being adjusted to
             Payment Source Other        indicate payment has been made by a third party insurer. If
    20
             Than Title XIX              TPL is involved, enter the 6-digit TPL carrier code.
                                         Void - Enter the information exactly as it appeared on the
                                         original invoice.

   21, 22                                Leave these spaces blank

    23       Diagram                     Not required

                                         Adjust - Enter the information exactly as it appeared on the
             Examination and             original invoice, unless this information is being adjusted
    24
             Treatment Plan              Void - Enter the information exactly as it appeared on the
                                         original invoice
                                         Adjust - Enter the information exactly as it appeared on the
                                         original invoice, unless this information is being adjusted to
                                         indicate payment has been made by a third party insurer. If
             Paid or Payable by Other
    25                                   such payment has been made, indicate the amount paid,
             Carrier
                                         even if zero ($0).
                                         Void - Enter the information exactly as it appeared on the
                                         original invoice
                                         Enter the control number assigned to the claim on the
    26       Control Number              Remittance Advice that reported the claim as
                                         paid/approved.
             Date of Remittance          Enter the date of the Remittance Advice that paid or denied
    27
             Advice                      claim
             Reasons for                 Check the appropriate box and give a written explanation,
   28, 29
             Adjustment/Void             when applicable.
    30       Request for Authorization   Leave this space blank.
                                         Enter the 9 digit PA number assigned by Medicaid on the
             Request for Prior
    31                                   authorized signature line when submitting for a service that
             Authorization
                                         requires prior authorization
             Attending Dentist's
    32                                   The provider number must be entered.
             Provider Number

If a new procedure or corrected procedure is entered on the adjustment form, and the new or
corrected procedure requires authorization, the completed adjustment form should be submitted
to the dental consultants for authorization prior to being submitted to Molina Medicaid Solutions
for adjustment. If the code was submitted on the original invoice, and prior authorization was
already obtained for the procedure, the provider does not need to submit the adjustment for
approval.




                                                   Page 26 of 30                                           Appendix D
LOUISIANA MEDICAID PROGRAM                      ISSUED:      08/01/12
                                             REPLACED:       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                 PAGE(S) 30

Example of 209 Adjustment/Void Form (EPSDT)




                             Page 27 of 30                 Appendix D
LOUISIANA MEDICAID PROGRAM                                                   ISSUED:                      08/01/12
                                                                          REPLACED:                       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                              PAGE(S) 30

         Instructions for Completing 210 Adjustment/Void Form (Adult)

Locator #         Description                                  Instructions                               Alerts
   1        Adj/Void                    Check the appropriate box.
                                        Adjust - Enter the information exactly as it appeared on the
   2        Patient's Last Name First
                                        original invoice
   3        Name
                                        Void - Enter the information exactly as it appeared on the
   4        MI
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice. If you wish to change this number, you
            Medical Assistance ID
   5                                    must first void the original claim.
            Number
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice.
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   6        Patient's Address
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   7        Date of Birth
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice
   8        Sex
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
  9-14                                  Not Required
                                        Adjust – Enter the information exactly as it appeared on the
            Patient ID/Account
                                        original invoice
   15       Number (Assigned By
                                        Void – Enter the information exactly as it appeared on the
            Dentist)
                                        original invoice
                                        Adjust – Enter the information exactly as it appeared on the
                                        original invoice
   16       Pay to Dentist or Group
                                        Void - Enter the information exactly as it appeared on the
                                        original invoice
                                        Adjust - Enter the information exactly as it appeared on the
                                        original invoice. If you wish to change this number, you
            Pay to Dentist or Group
   17                                   must first void the original claim.
            Provider No.
                                        Void – Enter the information exactly as it appeared on the
                                        original invoice
   18       Are X-Rays Enclosed         Not required
                                        Adjust - Enter the information exactly as it appeared on the
            Treatment Necessitated      original invoice.
   19
            By                          Void - Enter the information exactly as it appeared on the
                                        original invoice.




                                                  Page 28 of 30                                         Appendix D
LOUISIANA MEDICAID PROGRAM                                                     ISSUED:                       08/01/12
                                                                            REPLACED:                        12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                                                                 PAGE(S) 30

 Locator #         Description                                   Instructions                                Alerts
                                         Adjust - Enter the information exactly as it appeared on the
                                         original invoice unless the information is being adjusted to
             Payment Source Other        indicate payment has been made by a third party insurer. If
    20
             Than Title XIX              TPL is involved, enter the 6-digit TPL carrier code.
                                         Void - Enter the information exactly as it appeared on the
                                         original invoice.
    21                                   Not required

    22                                   Leave blank

                                         Adjust – Enter the information exactly as it appeared on the
                                         original invoice unless this information is being adjusted.
    23       A-G
                                         Void - Enter the information exactly as it appeared on the
                                         original invoice
                                         Adjust – Enter the information exactly as it appeared on the
                                         original invoice, unless this information is being adjusted to
                                         indicate payment has been made by a third party insurer. If
             Paid of Payable by Other
    24                                   such payment has been made, indicate the amount paid,
             Carrier
                                         even if zero ($0).
                                         Void - Enter the information exactly as it appeared on the
                                         original invoice
    25       Other Information           Leave blank
                                         Enter the control number assigned to the claim on the
    26       Control Number              Remittance Advice that reported the claim as
                                         paid/approved.
             Date of Remittance          Enter the date of the Remittance Advice that paid or denied
    27
             Advice                      claim
             Reasons for                 Check the appropriate box and give a written explanation,
   28, 29
             Adjustment/Void             when applicable.
    30       Request for Authorization   Leave this space blank.
                                         Enter the 9 digit PA number assigned by Medicaid on the
             Request for Prior
    31                                   authorized signature line when submitting for a service that
             Authorization
                                         requires prior authorization
             Attending Dentist's
    32                                   The provider number must be entered.
             Provider Number



If a new procedure or corrected procedure is entered on the adjustment form, and the new or
corrected procedure requires authorization, the completed adjustment form should be submitted to
the dental consultants for authorization prior to being submitted to Molina Medicaid Solutions for
adjustment. If the code was submitted on the original invoice, and prior authorization was already
obtained for the procedure, the provider does not need to submit the adjustment for approval.



                                                   Page 29 of 30                                           Appendix D
LOUISIANA MEDICAID PROGRAM                       ISSUED:      08/01/12
                                              REPLACED:       12/01/10
CHAPTER 40: RURAL HEALTH CLINICS
APPENDIX D: CLAIMS FILING                                  PAGE(S) 30

Example of 210 Adjustment/Void Form (Adult)




                              Page 30 of 30                 Appendix D

				
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