reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter A - General Provisions › Section IX-15105 - Fluoride Varnish Application Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
					 December 1, 2011, the Medicaid Program shall provide reimbursement for fluoride
					 varnish application services rendered by qualified health care professionals in
					 a physician office setting.
B.
					 Reimbursement for fluoride varnish application services shall be a flat fee
					 based on the appropriate HCPCS code.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter A - General Provisions › Section IX-15106 - Tobacco Cessation Counseling Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
					 June 20, 2023, the Medicaid Program shall provide reimbursement for tobacco
					 cessation counseling services rendered by qualified health care
					 professionals.
B. Reimbursement for
					 tobacco cessation counseling services shall be a flat fee based on the
					 appropriate HCPCS code.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter A - General Provisions › Section IX-15107 - Never Events

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective
					 for dates of service on or after July 1, 2012, the Medicaid Program will not
					 provide reimbursement to providers in the Professional Services Program for
					 "never events" or medical procedures performed in error which are preventable
					 and have a serious, adverse impact to the health of the Medicaid recipient.
					 Reimbursement will not be provided when the following "never events" occur:
1. the wrong surgical procedure is performed
					 on a patient;
2. surgical or
					 invasive procedures are performed on the wrong body part; or
3. surgical or invasive procedures are
					 performed on the wrong patient.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter A - General Provisions › Section IX-15109 - Elective Deliveries

Current through Register Vol. 50, No. 6, June 20, 2024
A. Induced
					 deliveries and cesarean sections by physicians or nurse midwives shall not be
					 reimbursed when performed prior to 39 weeks gestation. This shall not apply to
					 deliveries when there is a documented medical condition that would justify
					 delivery prior to 39 weeks gestation.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter A - General Provisions › Section IX-15110 - State-Owned or Operated Professional Services Practices

Current through Register Vol. 50, No. 6, June 20, 2024
A. Qualifying Criteria. Effective for dates
					 of service on or after February 1, 2018, in order to qualify to receive
					 enhanced rate payments for services rendered to Medicaid recipients under these
					 provisions, physicians and other eligible professional service practitioners
					 must be:
1. licensed by the state of
					 Louisiana;
2. enrolled as a
					 Louisiana Medicaid provider; and
3.
					 employed by, or under contract to provide services in affiliation with, a
					 state-owned or operated entity, such as a state-operated hospital or other
					 state entity, including a state academic health system, which:
a. has been designated by the department as
					 an essential provider. Essential providers include:
i. LSU School of Medicine-New
					 Orleans;
ii. LSU School of
					 Medicine-Shreveport; and
iii. LSU
					 state-operated hospitals (Lallie Kemp Regional Medical Center and Villa
					 Feliciana Geriatric Hospital).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter B - Physician Services › Section IX-15111 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Physicians shall be reimbursed according to the established fee schedule or
					 billed charges, whichever is the lesser amount.
B. Optometrists rendering eye care services
					 shall be reimbursed using the same methodology as physicians rendering the same
					 eye care services.
1. - 3.
					 Repealed.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter B - Physician Services › Section IX-15113 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after October 15, 2007, the reimbursement
					 for selected physician services shall be 90 percent of the 2007 Louisiana
					 Medicare Region 99 allowable or billed charges, whichever is the lesser amount,
					 unless otherwise stipulated.
1. If there is
					 no equivalent Medicare fee, the Medicaid fee shall be set based on the Medicare
					 fee for a similar service. In the absence of any applicable Medicare fee, the
					 fee shall be set at the Medicaid fee for a similar service or the Medicaid fee
					 for other states.
2. If
					 establishing a Medicaid fee based on Medicare rates results in a fee that is
					 reasonably expected to be insufficient to ensure that the service is available
					 to beneficiaries, an alternate methodology shall be used. The fee shall be set
					 at the Medicaid fee for a similar service or the Medicaid fee for other
					 states.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter C - Adjunct Services › Section IX-15121 - Payment for Adjunct Services

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after October 20, 2007, the Medicaid
					 Program shall provide reimbursement for the payment of adjunct services in
					 addition to the reimbursement for evaluation and management services and the
					 associated ancillary services when these professional services are rendered in
					 settings other than hospital emergency departments during evening, weekend or
					 holiday hours.
B. The reimbursement
					 for adjunct services is a flat fee, based on the Current Procedural Terminology
					 (CPT) procedure code, in addition to the reimbursement for the associated
					 evaluation and management services and associated ancillary services.
C. Reimbursement is limited to services
					 rendered between the hours of 5 p.m. and 8 a.m. Monday through Friday, on
					 weekends and state legal holidays. Documentation relative to this reimbursement
					 must include the time that the services were rendered.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter D - Anesthesia Services › Section IX-15131 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The most
					 appropriate procedure codes and modifiers shall be used when billing for
					 surgical anesthesia procedures and/or other services performed under the
					 professional licensure of the physician (anesthesiologist or other specialty)
					 or certified registered nurse anesthetist (CRNA).
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter D - Anesthesia Services › Section IX-15133 - Formula-Based Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Reimbursement is based on formulas related to a percentage of the 2009
					 Louisiana Medicare Region 99 allowable.
B. Effective for dates of service on or after
					 January 22, 2010, the reimbursement for formula-based anesthesia services
					 rendered by a physician shall be:
1. 75
					 percent of the 2009 Louisiana Medicare Region 99 allowable for services
					 rendered to Medicaid recipients ages 16 and older; and
2. 90 percent of the 2009 Louisiana Medicare
					 Region 99 allowable for services rendered to Medicaid recipients under the age
					 of 16.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter D - Anesthesia Services › Section IX-15135 - Flat Fee Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Reimbursement for maternity related anesthesia services is a flat fee, except
					 for general anesthesia related to a vaginal delivery which is reimbursed
					 according to a formula.
B. Other
					 anesthesia services that are performed under the professional licensure of the
					 physician (anesthesiologist or other specialty) or CRNA are reimbursed a flat
					 fee based on the appropriate procedure code.
C. Effective for dates of service on or after
					 February 26, 2009, the reimbursement rates paid to CRNAs will be reduced by 3.5
					 percent of the reimbursement as of February 25, 2009.
D. Effective for dates of service on or after
					 August 4, 2009, the reimbursement rates paid for anesthesia services that are
					 performed under the professional licensure of a physician (anesthesiologist or
					 other specialty) shall be reduced by 3.5 percent of the rates in effect on
					 August 3, 2009.
1. Effective for dates of
					 service on or after November 20, 2009, maternity-related anesthesia services
					 and anesthesia services rendered to recipients under the age of 16 shall be
					 exempt from the August 4, 2009 rate reduction on anesthesia services performed
					 by a physician (anesthesiologist or other specialty).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter E - Family Planning Services › Section IX-15141 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Reimbursement for family planning services shall be made according to the
					 established fee schedule or billed charges, whichever is the lesser
					 amount.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter E - Family Planning Services › Section IX-15143 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 reimbursement methodology for family planning services is the same as for
					 physician services.
B. - E.3.a.
					 Repealed.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter E - Family Planning Services › Section IX-15145 - Long-Acting Reversible Contraceptives (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter F - Supplemental Payments › Section IX-15151 - State-Owned or Operated Professional Services Practices

Current through Register Vol. 50, No. 6, June 20, 2024
A. Qualifying Criteria. Effective for dates
					 of service on or after February 21, 2017, in order to qualify to receive
					 supplemental payments, physicians and other eligible professional service
					 practitioners must be:
1. licensed by the
					 state of Louisiana;
2. enrolled as
					 a Louisiana Medicaid provider; and
3. employed by, or under contract to provide
					 services in affiliation with, a state-owned or operated entity, such as a
					 state-operated hospital or other state entity, including a state academic
					 health system, which:
a. has been designated
					 by the department as an essential provider. Essential providers include:
i. LSU School of Medicine-New
					 Orleans;
ii. LSU School of
					 Medicine-Shreveport;
iii. LSU
					 School of Dentistry; and
iv.
					 LSU-state-operated hospitals (Lallie Kemp Regional Medical Center and Villa
					 Feliciana Geriatric Hospital); and
b. has furnished satisfactory data to LDH
					 regarding the commercial insurance payments made to its employed physicians and
					 other professional service practitioners.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter F - Supplemental Payments › Section IX-15153 - Non-State-Owned or Operated Professional Services Practices

Current through Register Vol. 50, No. 6, June 20, 2024
A. Qualifying Criteria. Effective for dates
					 of service on or after February 21, 2017, in order to qualify to receive
					 supplemental payments, physicians and other eligible professional service
					 practitioners must be:
1. licensed by the
					 state of Louisiana;
2. enrolled as
					 a Louisiana Medicaid provider; and
3. employed by, or under contract to provide
					 services at a non-state owned or operated governmental entity and identified by
					 the non-state owned or operated governmental entity as a physician that is
					 employed by, or under contract to provide services at or in affiliation with
					 said entity.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter F - Supplemental Payments › Section IX-15155 - Qualifying Criteria-Professional Services of Practitioners Affiliated with Tulane School of Medicine

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after July 1, 2012, physicians and other
					 eligible professional service practitioners who are employed by a physician
					 group affiliated with Tulane University School of Medicine located in the city
					 of New Orleans may qualify for supplemental payments for services rendered to
					 Medicaid recipients. To qualify for the supplemental payment, the physician or
					 professional service practitioner must be:
1.
					 licensed by the state of Louisiana;
2. enrolled as a Louisiana Medicaid provider;
					 and
3. identified by Tulane
					 University School of Medicine as a physician or other professional service
					 practitioner that is employed by, or under contract to provide services for
					 that entity.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter G - Midwifery Services › Section IX-15161 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Certified nurse midwives and licensed midwives shall be reimbursed as a
					 percentage of physician reimbursement according to the established fee
					 schedule.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part IX - Professional Services Program › Subpart 15 - Reimbursement › Chapter 151 - Reimbursement Methodology › Subchapter G - Midwifery Services › Section IX-15163 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Effective for dates of service on or after August 1, 2023, services related to
					 pregnancy and childbirth provided by certified nurse midwives (including
					 licensed midwives), shall be reimbursed at 95 percent of the physician fee on
					 file.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 1 - Rehabilitation Clinics › Chapter 1 - General Provisions › Section XI-101 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Less Care by Others
- the ability of the
					 client to use a minimum of assistance to take care of personal needs.
Rehabilitation
- a program to prevent
					 further impairment of physical deformity and malfunction, and enable
					 significantly increased ability of the individual to require less care by
					 others.
Self-Care and Self Help
- the ability of
					 the individual to take care of personal needs, e.g., eating, dressing, ability
					 to walk, talk, or use devices unassisted.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 1 - Rehabilitation Clinics › Chapter 1 - General Provisions › Section XI-103 - Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Voice evaluation
				  or voice therapy coverage is excluded from the Title XIX Medical Assistance
				  Program. This includes instructions in use and hygiene of the voice as
				  treatment for vocal cord nodules or hoarseness, and related conditions, unless
				  it is serious enough to interfere with normal speech.
B. Effective for dates of service on or after
				  February 1, 2013, the department terminates the coverage of all rehabilitation
				  services to recipients 21 years of age and older.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 1 - Rehabilitation Clinics › Chapter 3 - Reimbursement › Section XI-301 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Medicaid Program provides reimbursement for physical therapy, occupational
				  therapy and speech therapy rendered in rehabilitation clinics to recipients
				  under the age of 21.
B. Effective
				  for dates of service on or after February 1, 2013, reimbursement shall not be
				  made for services rendered to recipients 21 years of age and older.
C. Effective for dates of service on or after
				  February 13, 2014, reimbursement for physical and occupational therapy services
				  shall be 85 percent of the 2013 Medicare published rate. There shall be no
				  automatic enhanced rate adjustment for physical and occupational therapy
				  services.
D. Speech/language
				  therapy services shall continue to be reimbursed at the flat fee in place as of
				  February 13, 2014 and in accordance with the Medicaid published fee schedule
				  for speech/language therapy services provided to recipients under the age of 21
				  in rehabilitation clinics.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 1 - Rehabilitation Clinics › Chapter 3 - Reimbursement › Section XI-303 - Reimbursement (Ages 0 up to 3) (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 5 - Family Planning › Chapter 35 - Reimbursement › Section XI-3501 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  reimbursement for family planning clinics is a flat fee for each covered
				  service as specified on the established Medicaid fee schedule. Fee schedule
				  rates are based on a percentage of the Louisiana Medicare Region 99 allowable
				  for a specified year.
B. Effective
				  for dates of service on or after August 1, 2010, the reimbursement rates for
				  family planning clinic services shall be 75 percent of the 2009 Louisiana
				  Medicare Region 99 allowable or billed charges, whichever is the lesser amount
				  minus any third party liability coverage.
C. Effective for dates of service on or after
				  July 1, 2012, the reimbursement rates for family planning clinics shall be
				  equal to the reimbursement rates for family planning services in the
				  Professional Services Program.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 7 - Prenatal Health Care › Chapter 51 - General Provisions › Section XI-5101 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Prenatal
				  health care services, provided by public prenatal health care clinics under the
				  auspices of the Office of Preventive and Public Health Services shall be
				  reimbursed under Title XIX as a covered service. Public health care service
				  clinics enrolled in the Title XIX Medicaid Program shall have reimbursement
				  limited to services each clinic is qualified to provide, and authorized under
				  42 CFR
				  440.90.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act,
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 9 - End Stage Renal Disease Facilities › Chapter 69 - Reimbursement › Section XI-6901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. End
				  stage renal disease (ESRD) facilities are reimbursed a hemodialysis composite
				  rate. The composite rate is a comprehensive payment for the complete
				  hemodialysis treatment in which the facility assumes responsibility for
				  providing all medically necessary routine dialysis services.
B. Covered non-routine dialysis services,
				  continuous ambulatory peritoneal dialysis (CAPD), continuous cycling peritoneal
				  dialysis (CCPD), epogen (EPO) and injectable drugs are reimbursed separately
				  from the composite rate.
1. Covered
				  non-routine laboratory services may be billed by either the ESRD facility or
				  the facilitys contracted outside laboratory.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 9 - End Stage Renal Disease Facilities › Chapter 69 - Reimbursement › Section XI-6903 - Medicare Part B Claims

Current through Register Vol. 50, No. 6, June 20, 2024
A. For Medicare
				  Part B claims, ESRD facilities are reimbursed for full co-insurance and
				  deductibles.
B. The Medicare
				  payment plus the amount of the Medicaid payment (if any) shall be considered to
				  be payment in full for the service. The recipient does not have any legal
				  liability to make payment for the service.
C. Effective for dates of service on or after
				  February 26, 2009, the reimbursement to ESRD facilities for Medicare Part B
				  claims shall be reduced by 3.5 percent of the rates in effect on February 25,
				  2009.
D. Effective for dates of
				  service on or after January 22, 2010, the reimbursement to ERSD facilities for
				  Medicare Part B claims shall be reduced by five percent of the rates in effect
				  on January 21, 2010.
E. Effective
				  for dates of service on or after August 1, 2010, the reimbursement to ESRD
				  facilities for Medicare Part B claims shall be reduced by 4.6 percent of the
				  rates in effect on July 31, 2010.
F. Effective for dates of service on or after
				  January 1, 2011, the reimbursement to ESRD facilities for Medicare Part B
				  claims shall be reduced by 2 percent of the rates in effect on December 31,
				  2010.
G. Effective for dates of
				  service on or after July 1, 2012, the reimbursement to ESRD facilities for
				  Medicare Part B claims shall be reduced by 3.7 percent of the rates in effect
				  on June 30, 2012.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 11 - Ambulatory Surgical Centers › Chapter 75 - Reimbursement › Section XI-7501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  services rendered by ambulatory surgical centers must be medically necessary
				  preventive, diagnostic, therapeutic, rehabilitative or palliative services
				  furnished to an outpatient by or under the direction of a physician or dentist
				  in a facility which is not part of a hospital but which is organized and
				  operated to provide medical care to patients.
B. This type of facility will not provide
				  services or accommodations for patients to stay overnight. Therefore, the
				  ambulatory surgical center shall have a system to transfer patients requiring
				  emergency admittance or overnight care to a fully licensed and certified Title
				  XIX hospital following any surgical procedure performed at the
				  facility.
C. Never Events.
				  Effective for dates of service on or after July 1, 2012, the Medicaid Program
				  will not provide reimbursement to ambulatory surgical centers for "never
				  events" or medical procedures performed in error which are preventable and have
				  a serious, adverse impact to the health of the Medicaid recipient.
				  Reimbursement will not be provided when the following "never events" occur:
1. the wrong surgical procedure is performed
				  on a patient;
2. surgical or
				  invasive procedures are performed on the wrong body part; or
3. surgical or invasive procedures are
				  performed on the wrong patient.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 11 - Ambulatory Surgical Centers › Chapter 75 - Reimbursement › Section XI-7503 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  reimbursement for surgical procedures performed in an ambulatory surgical
				  center is a flat fee per service in accordance with the four payment groups
				  established for ambulatory surgery services as specified on the Medicaid fee
				  schedule.
1. The flat fee reimbursement is
				  for facility charges only, which covers all operative functions associated with
				  the performance of a medically necessary surgery including admission, patient
				  history and physical, laboratory tests, operating room staffing, recovery room
				  charges, all supplies related to the surgical care of the patient and
				  discharge.
2. The flat fee excludes
				  payments for the physician performing the surgery, the radiologist and the
				  anesthesiologist when these professionals are not under contract with the
				  ambulatory surgery center.
3.
				  Effective for dates of service on or after September 20, 2021, the Medicaid
				  Program shall provide reimbursement for COVID-19 laboratory testing in addition
				  to the ambulatory surgical center flat fee reimbursement
				  amount.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 101 - General Provisions › Section XI-10101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A.Section 330 of
				  the Public Health Service (PHS) Act of 1991 authorized the development of
				  federally qualified health centers (FQHCs) through a grant funding program to
				  provide care and improve the health status of medically underserved
				  populations.
B. The U.S. Department
				  of Health and Human Services, Health Resources and Services Administration
				  (HRSA), certifies the FQHC status of organizations that receive grant funding
				  under Section 330 of the PHS Act.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 103 - Services › Section XI-10301 - Scope of Services [Formerly section 10501]

Current through Register Vol. 50, No. 6, June 20, 2024
A. 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. The following services shall be
				  covered:
1. services furnished by a physician
				  within the scope of practice of his profession under Louisiana law;
2. services furnished by a:
a. physician assistant;
b. nurse practitioner;
c. nurse midwife;
d. clinical social worker;
e. clinical psychologist; or
f. dentist;
3. services and supplies that are furnished
				  as an incident to professional services furnished by all eligible
				  professionals;
4. other ambulatory
				  services; and
5. diabetes
				  self-management training (DSMT) services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 103 - Services › Section XI-10303 - Service Limits [Formerly section 10503]

Current through Register Vol. 50, No. 6, June 20, 2024
A. There shall be no limits placed on the
				  number of federally qualified health center visits (encounters) payable by the
				  Medicaid program for eligible beneficiaries.
B. - B.1. Repealed.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 105 - Provider Participation › Section XI-10501 - Provider Enrollment [Formerly Section 10301]

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to enroll and participate in the
				  Medicaid Program, an FQHC must submit a completed provider enrollment packet
				  that includes a copy of the HRSA grant approving its FQHC status.
B. The effective date of a FQHC's enrollment
				  to participate in the Medicaid Program shall not be prior to the date of
				  receipt of the completed enrollment packet.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 105 - Provider Participation › Section XI-10503 - Standards for Participation [Formerly section 10303]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Federally qualified health centers must
				  comply with the applicable licensure, accreditation and program participation
				  standards for all services rendered. If a FQHC wishes to initiate
				  participation, it shall be responsible for meeting all of the enrollment
				  criteria of the program. The FQHC provider shall:
1. maintain an acceptable fiscal record
				  keeping system that readily distinguishes one type of service from another type
				  of service that may be provided;
2.
				  retain all records necessary to fully disclose the extent of services provided
				  to beneficiaries for five years from the date of service and furnish such
				  records, and any payments claimed for providing such services, to the Medicaid
				  Program upon request; and
3. abide
				  by and adhere to all federal and state regulations and policy
				  manuals.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 107 - Reimbursement Methodology › Section XI-10701 - Prospective Payment System

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Payments for Medicaid covered services will be made under a prospective payment
				  system (PPS) and paid on a per visit basis.
B. A visit is defined as a face-to-face
				  encounter between a facility health professional and a Medicaid eligible
				  patient for the purpose of providing medically necessary outpatient services.
1. Encounters with more than one facility
				  health professional that take place on the same day and at a single location
				  constitute a single encounter.
2.
				  Services shall not be arbitrarily delayed or split in order to bill additional
				  encounters.
NOTE: Refer to the FQHC and Physician's Current Procedural
					 Terminology (CPT) Manuals for the definition of an encounter.
3. Effective for dates of service on or after
				  February 20, 2011, the Medicaid Program shall include coverage for diabetes
				  self-management training services rendered by qualified health care
				  professionals in the FQHC encounter rate.
a.
				  Separate encounters for DSMT services are not permitted and the delivery of
				  DSMT services alone does not constitute an encounter visit.
4. Effective for dates of service
				  on or after December 1, 2011, the Medicaid Program shall include coverage for
				  fluoride varnish applications in the FQHC encounter rate.
a. Fluoride varnish applications shall only
				  be reimbursed to the FQHC when performed on the same date of service as an
				  office visit or preventive screening. Separate encounters for fluoride varnish
				  services are not permitted and the application of fluoride varnish does not
				  constitute an encounter visit.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 13 - Federally-Qualified Health Centers › Chapter 107 - Reimbursement Methodology › Section XI-10703 - Alternate Payment Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after October 20, 2007, the Medicaid
				  Program establishes an alternate payment methodology for adjunct services
				  provided by federally qualified health centers (FQHCs) when these professional
				  services are rendered during evening, weekend or holiday hours. This alternate
				  payment methodology is in addition to the prospective payment system
				  methodology established for FQHC services.
1.
				  A payment for adjunct services is not allowed when the encounter is for dental
				  services only.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 161 - General Provisions › Section XI-16101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Rural Health
				  Clinic (RHC) Act of 1977 authorized the development of rural health clinics to
				  encourage and stabilize the provision of outpatient primary care in rural areas
				  through cost-based reimbursement.
B. Rural health clinic regulations
				  distinguish between two types of rural health clinics.
1. The independent RHC is a free-standing
				  practice that is not part of a hospital, skilled nursing facility, or home
				  health agency.
2. The
				  provider-based RHC is an integral and subordinate part of a hospital, skilled
				  nursing facility, or home health agency.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 163 - Services › Section XI-16301 - Scope of Services [Formerly section 16501]

Current through Register Vol. 50, No. 6, June 20, 2024
A. 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 . The following services shall be
				  covered:
1. services furnished by a
				  physician, within the scope of practice of his profession under Louisiana
				  law;
2. services furnished by a:
a. physician assistant;
b. nurse practitioner;
c. nurse midwife;
d. clinical social worker;
e. clinical psychologist; or
f. dentist;
3. services and supplies that are furnished
				  as an incident to professional services furnished by all eligible
				  professionals;
4. other ambulatory
				  services; and
5. diabetes
				  self-management training (DSMT) services.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 163 - Services › Section XI-16303 - Service Limits [Formerly section 16503]

Current through Register Vol. 50, No. 6, June 20, 2024
A. There shall be no limits placed on rural
				  health clinic visits (encounters) payable by the Medicaid program for eligible
				  beneficiaries.
B. - B.1.
				  Repealed.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 165 - Provider Participation [Formerly Chapter 163] › Section XI-16501 - Provider Enrollment [Formerly Section 16301]

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to enroll and participate in the
				  Medicaid Program, a RHC must submit a completed provider enrollment
				  packet.
B. The effective date of
				  enrollment to participate in the Medicaid Program shall not be prior to the
				  date of receipt of the completed enrollment packet.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 165 - Provider Participation [Formerly Chapter 163] › Section XI-16503 - Standards for Participation [Formerly section 16303]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Rural health clinics must comply with the
				  applicable licensure, accreditation and program participation standards for all
				  services rendered. If a RHC wishes to initiate participation, it shall be
				  responsible for meeting all of the enrollment criteria of the program. The RHC
				  provider shall:
1. maintain an acceptable
				  fiscal record keeping system that readily distinguishes one type of service
				  from another type of service that may be provided;
2. retain all records necessary to fully
				  disclose the extent of services provided to beneficiaries for five years from
				  the date of service and furnish such records, and any payments claimed for
				  providing such services, to the Medicaid Program upon request; and
3. abide by and adhere to all federal and
				  state regulations and policy manuals.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 167 - Reimbursement Methodology › Section XI-16701 - Prospective Payment System

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Payments for Medicaid covered services will be made under a Prospective Payment
				  System (PPS) and paid on a per visit basis.
B. A visit is defined as a face-to-face
				  encounter between a facility health professional and a Medicaid eligible
				  patient for the purpose of providing medically needed outpatient services.
1. Encounters with more than one facility
				  health professional that take place on the same day and at a single location
				  constitute a single encounter.
2.
				  Services shall not be arbitrarily delayed or split in order to bill additional
				  encounters.
NOTE: Refer to the RHC and Physician's Current Procedural
					 Terminology (CPT) Manuals for the definition of an encounter.
3. Effective for dates of service on or after
				  February 20, 2011, the Medicaid Program shall include coverage for diabetes
				  self-management training services rendered by qualified health care
				  professionals in the RHC encounter rate.
a.
				  Separate encounters for DSMT services are not permitted and the delivery of
				  DSMT services alone does not constitute an encounter visit.
4. Effective for dates of service
				  on or after December 1, 2011, the Medicaid Program shall include coverage for
				  fluoride varnish applications in the RHC encounter rate.
a. Fluoride varnish applications shall only
				  be reimbursed to the RHC when performed on the same date of service as an
				  office visit or preventive screening. Separate encounters for fluoride varnish
				  services are not permitted and the application of fluoride varnish does not
				  constitute an encounter visit.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 167 - Reimbursement Methodology › Section XI-16703 - Alternate Payment Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after October 20, 2007, the Medicaid
				  Program establishes an alternate payment methodology for adjunct services
				  provided by rural health clinics (RHCs) when these professional services are
				  rendered during evening, weekend or holiday hours. This alternate payment
				  methodology is in addition to the Prospective Payment System methodology
				  established for RHC services.
1. A payment
				  for adjunct services is not allowed when the encounter is for dental services
				  only.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XI - Clinic Services › Subpart 15 - Rural Health Clinics › Chapter 167 - Reimbursement Methodology › Section XI-16705 - Hospital-Based Rural Health Clinics

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective for dates of service on or after
				  July 1, 2008, the reimbursement methodology for services rendered by a rural
				  health clinic that was licensed as part of a small rural hospital as of July 1,
				  2007 shall be as follows:
1. Hospital-based
				  rural health clinics shall be reimbursed in the aggregate at 110 percent of
				  reasonable costs.
2. The interim
				  payment for claims shall be the Medicaid Benefits Improvement and Protection
				  Act of 2000 (BIPA) Prospective Payment System (PPS) per visit rate currently in
				  effect for each provider. Final reimbursement shall be the greater of BIPA PPS
				  payments or the alternative payment methodology of 110 percent of allowable
				  costs as calculated through the cost settlement process.
3. The payment received under this
				  methodology will be compared each year to the BIPA PPS rate to assure the
				  clinic that their payment under this alternative payment methodology (APM) is
				  at least equal to the BIPA PPS rate. If the payment calculation at 110 percent
				  of allowable cost is less than the BIPA PPS payments, the clinic will be paid
				  the difference.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 1 - General Provisions › Section XIII-103 - Requirements for Home Health Services [Formerly LAC 50:XIX.103]

Current through Register Vol. 50, No. 6, June 20, 2024
A. Home health
				  services shall be based on an expectation that the care and services are
				  medically reasonable and appropriate for the treatment of an illness or injury,
				  and that the services can be performed adequately by the agency in the
				  recipient's home or place of residence. For initial ordering of home health
				  services, the authorized healthcare provider must document a face-to-face
				  encounter that is related to the primary reason the recipient requires home
				  health services. This face-to-face encounter must occur no more than 90 days
				  before or 30 days after the start of services. For the initial ordering of
				  medical supplies, equipment and appliances, the authorized healthcare provider
				  must document that a face-to-face encounter that is related to the primary
				  reason the recipient requires medical equipment occurred no more than six
				  months prior to the start of services. A written plan of care for services
				  shall be evaluated and signed by the authorized healthcare provider every 60
				  days. This plan of care shall be maintained in the recipient's medical records
				  by the home health agency.
B. Home
				  health services shall be provided in the recipient's home or place of
				  residence.
AUTHORITY
					 NOTE: Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIII - Home Health Program › Subpart 1 - Home Health Services › Chapter 1 - General Provisions › Section XIII-104 - Emergency Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY
					 NOTE: Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.