TAKE CHARGE PLUS (FAMILY PLANNING SERVICES) PROVIDER MANUAL Chapter Forty-Eight of the Medicaid Services Manual

Transcription

1 TAKE CHARGE PLUS (FAMILY PLANNING SERVICES) PROVIDER MANUAL Chapter Forty-Eight of the Medicaid Services Manual Issued October 16, 2014 Claims/authorizations for dates of service on or after October 1, 2015 must use the applicable ICD-10 diagnosis code that reflects the policy intent. References in this manual to ICD-9 diagnosis codes only apply to claims/authorizations with dates of service prior to October 1, State of Louisiana Bureau of Health Services Financing

2 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION: TABLE OF CONTENTS PAGE(S) 2 FAMILY PLANNING TAKE CHARGE PLUS TABLE OF CONTENTS SUBJECT SECTION OVERVIEW SECTION 48.0 COVERED SERVICES SECTION 48.1 Family Planning Services Family Planning-Related Services Return Visits Pharmaceuticals and Supplies Service Limitations Primary Care Services (Non-Covered) Sterilization RECIPIENT REQUIREMENTS SECTION 48.2 Eligibility Verification MEVS Eligibility Confirmation REVS Eligibility Confirmation PROVIDER PARTICIPATION SECTION 48.3 REIMBURSEMENT SECTION 48.4 Billing Information Adjusting/Voiding Claims RECORDING KEEPING SECTION 48.5 Content and Organization of the Medical Record Confidentiality and Release of Records Page 1 of 2 Table of Contents

3 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION: TABLE OF CONTENTS PAGE(S) 2 DIAGNOSIS CODES FREQUENT CONTACT INFORMATION APPENDIX A APPENDIX B Page 2 of 2 Table of Contents

4 LOUISIANA MEDICAID PROGRAM ISSUED: 02/11/15 REPLACED: 10/16/14 SECTION: OVERVIEW PAGE(S) 1 OVERVIEW Since 1972, states have been required to provide family planning services and supplies to Medicaid populations, but not to individuals otherwise ineligible for Medicaid. However, the Centers for Medicare and Medicaid Services (CMS) would allow states to provide family planning services and supplies for individuals not otherwise eligible for Medicaid through Research and Demonstration Waivers under Section 1115 of the Social Security Act. Louisiana requested and received approval in June 2006 to provide such services through the TAKE CHARGE Waiver. The TAKE CHARGE Waiver program ended December 31, Section 2303 of the Affordable Care Act (ACA) establishe d a new Medicaid eligibility group entitled, State Eligibility Option for Family Planning Services. Federal funding was made available and states now have the option to provide coverage, under State Plan authority, for family planning and family planning-related services and supplies to individuals (male and female of child bearing age) that could previously only be offered through demonstration projects. Effective July 1, 2014, the Louisiana Medicaid Program began providing coverage of family planning services and supplies under the Medicaid State Plan to this new eligibility group through Take Charge Plus. This program is designed to increase access to services which will allow improved reproductive and physical health, improved perinatal outcomes, and reduce the number of unintended pregnancies. In addition, the program is designed to decrease the rates of sexually transmitted infections (STIs) and thus help to improve birth outco mes. Services available to individuals under this program include family planning and family planning-related services. Any enrolled Medicaid provider whose scope of practice includes family planning health services may offer these services. Page 1 of 1 Section 48.0

5 LOUISIANA MEDICAID PROGRAM ISSUED: 11/24/14 REPLACED: 10/16/14 SECTION 48.1: COVERED SERVICES PAGE(S) 3 COVERED SERVICES The primary goal of family planning services is to increase access to services which will allow improved reproductive and physical health, improve perinatal outcomes, and reduce the number of unintended pregnancies. Services available to individuals under this program include family planning and family planning-related services. Family Planning Services Medicaid covered family planning services include: Seven evaluation and management office visits per year for physical examinations for both males and females as it relates to family planning or family planningrelated services; Contraceptive counseling (including natural family planning), education, followups, and referrals; Laboratory procedures for the purposes of family planning and management of sexual health; Pharmaceutical supplies and devices to prevent conception, including all methods of contraception approved by the Federal Food and Drug Administration; and Male and female sterilization procedures and follow up tests. Family Planning-Related Services Family planning-related services include the diagnosis and treatment of sexually transmitted diseases or infections, regardless of the purpose of the visit at which the disease or infection was discovered. Medicaid covered family planning-related services include: Diagnostic procedures to identify and diagnose a sexually transmitted disease (STD) or infection (STI); Page 1 of 3 Section 48.1

6 LOUISIANA MEDICAID PROGRAM ISSUED: 11/24/14 REPLACED: 10/16/14 SECTION 48.1: COVERED SERVICES PAGE(S) 3 Drugs and follow-up visits to treat a sexually transmitted disease, infection or disorder identified or diagnosed at a family planning visit, except for HIV/AIDS and hepatitis; Vaccine to prevent human papillomavirus (HPV); Treatment of major complications from certain family planning procedures, which may result in inpatient services, such as: Treatment of a perforated uterus due to an intrauterine device (IUD) insertion; Treatment of severe menstrual bleeding caused by a Depo-Provera injection requiring a dilation and curettage; or Treatment of surgical or anesthesia-related complications during a sterilization procedure; and Non-emergency transportation services. Return Visits Return visits (excluding routine supply visits) include an assessment of the recipient's health status, current complaints, and an evaluation of birth control method and an opportunity to change these methods. Pharmaceuticals and Supplies The pharmaceuticals (drugs, supplies, and devices) covered in the outpatient pharmacy program for the family planning program includes all Federal Food and Drug Administration (FDA) approved contraceptives such as: Birth control pills and condoms; Intra uterine devices (IUDs); Implants and patches; and Diaphragms and spermicides. Page 2 of 3 Section 48.1

7 LOUISIANA MEDICAID PROGRAM ISSUED: 11/24/14 REPLACED: 10/16/14 SECTION 48.1: COVERED SERVICES PAGE(S) 3 There are select drugs which are covered by Take Charge Plus for the treatment of sexually transmitted diseases (STDs) and sexually transmitted infections (STIs). Service Limitations A limit of SEVEN evaluation and management office visits per calendar year (including initial visit and subsequent visits) has been established for services provided by physicians, nurse practitioners, and/or physician assistants, based on approved procedure codes (see Appendix B for information on accessing the Take Charge Plus Fee Schedule). Primary Care Services (Non-Covered) Primary care services are not covered by Take Charge Plus. However, if a need for primary care services is identified during a family planning or family planning-related visit, the health care provider is responsible for informing the recipient that these services are not covered. Examples of non-covered services include but are not limited to: Mammograms Hysterectomy Emergency room visits Sterilization Sterilizations must comply with Medicaid program requirements. Please refer to Section 5.1 of the Professional Services provider manual for the entire sterilization policy. Recipients who have received sterilization services under Take Charge Plus will only receive family planning-related services in connection with, or as a result of, the sterilization visit. NOTE: Refer to Appendix A for a list of diagnosis codes. Page 3 of 3 Section 48.1

8 LOUISIANA MEDICAID PROGRAM ISSUED: 11/24/14 REPLACED: 10/16/14 SECTION 48.2: RECIPIENT REQUIREMENTS PAGE(S) 2 RECIPIENT REQUIREMENTS Family planning and family planning-related services are available through Take Charge Plus, to Louisiana residents, both males and females (who are not pregnant) of child bearing age, regardless of whether or not they have other health insurance, who meet the following criteria: Have family income at or below 138 percent of the Federal Poverty Level; Are not eligible for any other Medicaid program; and Are not sterilized prior to program participation. Eligibility Verification It is the provider s responsibility to verify eligibility prior to services being rendered. Recipient eligibility is verified by swiping the Medicaid card using the Medicaid Eligibility Verification System (MEVS) or by telephoning the Recipient Eligibility Verification System (REVS). MEVS Eligibility Confirmation The information identified in the confirmation of eligibility in MEVS is contingent on the type of provider making the inquiry. The following chart is an example of the information provided during an inquiry by a hospital provider. Health Benefit Plan Coverage Benefit Active Coverage Benefit Description Coverage Level Individual Insurance Type Medicaid Plan Coverage Description TAKE CHARGE PLUS SERVICES REFER TO INFORMATION FOR BILLABLE CODES Individual Medicaid Recipient Entitled To Limited Benefits. Benefit Description Individual Medicaid Preferred Language: English. Page 1 of 2 Section 48.2

9 LOUISIANA MEDICAID PROGRAM ISSUED: 11/24/14 REPLACED: 10/16/14 SECTION 48.2: RECIPIENT REQUIREMENTS PAGE(S) 2 Service Limitations Coverage Level Service Type Insurance Type Units Individual Professional (Physician) Visit - Office Medicaid 7 Visits Remaining REVS Eligibility Confirmation Providers who verify eligibility via REVS will receive the following information when confirming eligibility: The Recipient is eligible for TAKE CHARGE PLUS Services only. Benefits are limited. The recipient has X Family Planning visits remaining. Page 2 of 2 Section 48.2

10 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION 48.3: PROVIDER PARTICIPATION PAGE(S) 1 PROVIDER PARTICIPATION Family planning services may be provided by any Medicaid-enrolled provider, whose scope of practice permits the delivery of family planning and family planning-related services, including, but not limited to: Physicians; Advanced practice registered nurses (APRNs); Physician assistants (PAs); Family planning clinics; Federally qualified health centers (FQHCs); Rural health clinics (RHCs); and Tribal/American Indian 638 clinics. Page 1 of 1 Section 48.3

11 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION 48.4: REIMBURSEMENT PAGE(S) 2 REIMBURSEMENT Providers of Take Charge Plus services, including federally qualified health centers (FQHCs), rural health clinics (RHCs) and American Indians 638 clinics will be reimbursed at the Medicaid fee-for-service rates published on the Take Charge Plus fee schedule. Non physician providers (NPP), nurse practitioners and physician assistants, will be reimbursed using the same methodology as the Professional Services Program. Take Charge Plus offers a limited benefit package of family planning and family planningrelated services which includes: Professional services; Outpatient hospital services; Ambulatory surgical center services; Limited inpatient services (see Covered Services); Laboratory and radiology services; and Pharmaceutical services. Billing Information Claims processing for family planning services and family planning-related services will be conducted through the fiscal intermediary (FI). In order for providers to receive reimbursement, the primary purpose of the visit must be family planning or family planning-related. Claims for Take Charge Plus recipients must have a primary diagnosis code from the approved list of family planning or family planning-related diagnosis codes. (See Appendix A). Page 1 of 2 Section 48.4

12 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION 48.4: REIMBURSEMENT PAGE(S) 2 Providers shall accept as payment in full the amounts established by the Medicaid Program, and must not seek additional payment from the recipient for any unpaid portion of a bill. A recipient may be billed for services which have been determined as non-covered or exceeding a limitation set by the Medicaid Program. Recipients are also responsible for all services rendered after eligibility has ended. Adjusting/Voiding Claims An adjustment or void may be submitted to the FI electronically or by using the CMS-1500 (02/12) form. Only a paid claim can be adjusted or voided. Denied claims must be corrected and resubmitted not adjusted or voided. The provider should complete the information on the adjustment exactly as it appeared on the original claim, changing only the item(s) that was in error and noting the reason for the change in the space provided on the claim. If a paid claim is being voided, the provider must enter all the information on the void from the original claim exactly as it appeared on the original claim. After a voided claim has appeared on the Remittance Advice, a corrected claim may be resubmitted (if applicable). Please refer to Appendix E of the Professional Services provider manual for additional information regarding adjusting and/or avoiding claims. Page 2 of 2 Section 48.4

13 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION 48.5 RECORD KEEPING PAGE(S) 2 RECORD KEEPING Records must be maintained in an organized and standardized format and comply with accepted medical record keeping standards. All records must be retained for a period of six years from the date the recipient was last treated. In the case of an audit, the records must be maintained until the audit is complete, even if the six years is exceeded. Refer to chapter one of the Medicaid Services Manual (General Information and Administration) for more information regarding record keeping. Content and Organization of the Medical Record The records must contain sufficient information to identify the recipient, indicate contact information, justify clinical diagnosis, and warrant the treatment and end results. The required content includes: Personal data; Medical history, physical exam, clinical findings, diagnostic/laboratory orders, results, and treatment; Scheduled follow-up visits when necessary; Telephone encounters of a clinical nature; Documentation of continuing care, referral, and follow up; Signed informed consent; Signed refusal of services; Allergies and drug reactions; and Entries by counseling and social service staff. Page 1 of 2 Section 48.5

14 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: SECTION 48.5 RECORD KEEPING PAGE(S) 2 Records must be: Systematically organized, complete, legible, and accurate; Signed by the clinician (name, title, date); Readily accessible immediately upon request by authorized state and federal agencies or their authorized representatives which includes, but is not limited to, the Department of Health and Hospitals, the State Attorney General s Medicaid Fraud Control Unit and the Department of Health and Human Services; Supportive of the services provided; Confidential, safeguarded against loss or use by unauthorized persons; and Available for review upon the recipient s request. Confidentiality and Release of Records Providers must: Maintain a confidentiality assurance statement and HIV information according to state law and be kept separate whenever possible; Have the recipient s written consent for the release of personal identifiable information, except as may be necessary to provide services or as required by law; and Comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations and other applicable state and federal laws. Page 2 of 2 Section 48.5

15 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 DIAGNOSIS CODES Take Charge Plus offers a limited benefit package of family planning and family planningrelated services which includes professional services, outpatient services, and laboratory/radiology and pharmaceutical services. With the exception of the services billed by pharmacists, all services must be submitted using an appropriate primary diagnosis. For dates of service prior to 10/01/15, the ICD-9 diagnosis codes in the following list are applicable. For dates of service on or after 10/01/15, providers must use the applicable ICD-10 diagnosis code that continues to reflect the intent and purpose of Take Charge Plus. Diagnosis Code Description V01.6 VENEREAL DIS CONTACT V04.89 NEED PROPH VAC & INOCULAT OTH VIEL DZ V05.8 VACCIN FOR DISEASE NEC V25.01 PRESCRIP-ORAL CONTRACEPT V25.02 INITIATE CONTRACEPT NEC V25.03 ENCOUNTER EMERG CNTRAC PT CNSL & PRSC V25.04 CNSL&&INSTR NATURL FAM PLAN AVOID PG V25.09 CONTRACEPTIVE MANGMT NEC V25.11 ENC INSERTION IU CONTRACEPT DEVICE V25.12 ENC REMOVAL IU CONTRACEPTIVE DEVICE V25.13 ENC REMV REINS IU CONTRACEPT DEVICE V25.2 STERILIZATION V25.3 MENSTRUAL EXTRACTION Page 1 of 9 Appendix A

16 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description V25.40 CONTRACEPT SURVEILL NOS V25.41 CONTRACEPT PILL SURVEILL V25.42 IUD SURVEILLANCE V25.43 IMPLANTABLE SUBDERMAL CONTRACEPTIVE V25.49 CONTRACEPT SURVEILL NEC V25.5 INSERTION IMPLANTABLE SUBDERM CONTRACEPT V25.8 CONTRACEPTIVE MGMT NECS V25.9 CONTRACEPTIVE MANGMT NOS V26.51 TUBAL LIGATION STATUS V26.52 VASECTOMY STATUS V45.51 PRESENCE OF INTRA CONTRACEP DEVICE V45.52 PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT V45.59 PRESENCE OF OTHER CONTRACEPTIVE DEVICE V67.09 FLU EXAM FOLLOW OTH SURG V72.31 ROUTINE GYNECOLOGICAL EXAMINATION V72.60 LABORATORY EXAMINATION UNSPECIFIED GENITAL HERPES NOS HERPETIC VULVOVAGINITIS Page 2 of 9 Appendix A

17 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description HERPETIC ULCER OF VULVA HERPETIC INFECT OF PENIS GENITAL HERPES NEC MOLLUSCUM CONTAGIOSUM VIRAL WARTS, UNSPECIFIED CONDYLOMA ACUMINATUM PRIMARY GENITAL SYPHILIS PRIMARY ANAL SYPHILIS PRIMARY SYPHILIS NEC SECONDARY SYPH SKIN SYPHILITIC ADENOPATHY SYPHILITIC UVEITIS NOS SYPHILIT CHORIORETINITIS SYPHILITIC IRIDOCYCLITIS SYPHILITIC PERIOSTITIS SYPHILITIC HEPATITIS SECOND SYPH VISCERA NEC SECOND SYPHILIS RELAPSE Page 3 of 9 Appendix A

18 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description ACUTE SYPHIL MENINGITIS SYPHILITIC ALOPECIA SECONDARY SYPHILIS NEC SECONDARY SYPHILIS NOS EARLY SYPH LATENT RELAPS EARLY SYPHIL LATENT NOS 096 LATE SYPHILIS LATENT LATENT SYPHILIS NOS ACUTE GC INFECT LOWER GU GC (ACUTE) UPPER GU NOS GC CYSTITIS (ACUTE) GC PROSTATITIS (ACUTE) GC ORCHITIS (ACUTE) GC SEM VESICULIT (ACUTE) GC CERVICITIS (ACUTE) GC ENDOMETRITIS (ACUTE) ACUTE GC SALPINGITIS GC (ACUTE) UPPER GU NEC Page 4 of 9 Appendix A

19 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description CHR GC INFECT LOWER GU CHANCROID LYMPHOGRANULOMA VENEREUM UNSPECIFIED, NONSPECIFIC URETHRITIS CHLAMYDIA TRACHOMATIS UNSPECIFIED SITE CHLAMYDTRACHOMATIS INF ANUS&RECTUM CHLAMYDTRACHOMATIS INF LOWER GU SITES CHLAMYDTRACHOMATIS INF OTH GU SITES CHLAMYDTRACHOMAT INF UNSPEC GU SITE CHLAMYDTRACHOMATIS INF PERITONEUM CHLAMYDTRACHOMATIS INF OTH SPEC SITE CANDIDAL VULVOVAGINITIS CANDIDAL BALANITIS UROGENITAL TRICHOMON NOS TRICHOMONAL VAGINITIS TRICHOMONAL URETHRITIS TRICHOMONAL PROSTATITIS Page 5 of 9 Appendix A

20 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description UROGENITAL TRICHOMON NEC CA IN SITU CERVIX UTERI ACUTE CYSTITIS CHR INTERSTIT CYSTITIS CHRONIC CYSTITIS NEC TRIGONITIS CYSTITIS IN OTH DIS CYSTITIS CYSTICA IRRADIATION CYSTITIS CYSTITIS NEC CYSTITIS NOS URETHRAL ABSCESS URETHRITIS NOS URETHRAL SYNDROME NOS URETHRITIS NEC URIN TRACT INFECTION NOS HEMATURIA UNSPECIFIED GROSS HEMATURIA Page 6 of 9 Appendix A

21 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description MICROSCOPIC HEMATURIA ORCHITIS/EPIDIDYMIT NOS OTHER INFLAMMATORY DISORDERS OF PENIS MALE GENITAL DIS NEC AC SALPINGO-OOPHORITIS CHR SALPINGO-OOPHORITIS SALPINGO-OOPHORITIS NOS ACUTE PARAMETRITIS CHRONIC PARAMETRITIS AC PELV PERITONITIS-FEM FEM PELVIC PERITON ADHES CHR PELV PERITON NEC-FEM FEM PELV INFLAM DIS NEC FEM PELV INFLAM DIS NOS AC UTERINE INFLAMMATION CHR UTERINE INFLAMMATION UTERINE INFLAM DIS NOS CERVICITIS Page 7 of 9 Appendix A

22 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description VAGINITIS NOS VAGINITIS IN OTH DISEASE BARTHOLIN'S GLAND CYST BARTHOLIN'S GLND ABSCESS ABSCESS OF VULVA NEC ULCERATION OF VULVA NOS VULVAR ULCER IN OTH DIS MUCOSITIS OF CERVIX VAGINAL & VULVA OTH INFLAM DZ CERVIX VAGINA & VULVA FEMALE GEN INFLAM NOS MILD EYSPLASIA OF CERVIX MODERATE DYSPLASIA OF CERVIX LEUKOPLAKIA OF CERVIX NONINFECT VAG LEUKORRHEA DYSPAREUNIA FEM GENITAL SYMPTOMS NOS DYSURIA DYSFUNCTIONAL OR FUNCTIONAL UTERINE HEMORRHAGE NOS Page 8 of 9 Appendix A

23 LOUISIANA MEDICAID PROGRAM ISSUED: 09/25/15 REPLACED: 11/25/14 APPENDIX A: DIAGNOSIS CODES PAGE(S) 9 Diagnosis Code Description URINARY FREQUENCY URETHRAL DISCHARGE ABDOMINAL PAIN, OTHER SPECIFIED SITE NONSPEC ABNORM PAP SMEAR CERV UNSPEC PAP SMEAR CERVIX WITH ASC-US PAP SMEAR CERVIX WITH ASC-H PAP SMEAR CERVIX WITH LGSIL PAP SMEAR CERVIX WITH HGSIL CERV HIGH RISK HPV DNA TEST POS PAP SMEAR CERV CYTOL EVIDENCE MALIG NONSPC ABN PAP SMER CERV UNSAT SMER OTH NONSPEC ABNORM PAP SMEAR CERV MECHANICAL COMPLICATION DUE TO IUD INFECTION AND INFLAMMATORY REACTION DUE TO IUD OTHER COMPLICATIONS OF IUD HEMORRHAGE COMPLICATING A PROCEDURE Page 9 of 9 Appendix A

24 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: CHAPTER 48: FAMILY PLANNING- TAKE CHARGE PLUS SECTION: FREQUENT CONTACT INFORMATION PAGE(S) 4 Molina Medicaid Solutions CONTACT INFORMATION The Medicaid Program s fiscal intermediary, Molina Medicaid Solutions can be contacted for assistance with the following: TYPE OF ASSISTANCE e-cdi technical support Electronic Media Claims (EMC) Electronic Claims sign up and testing Pre-Certification Unit (Hospital) Pre-certification issues and forms Pharmacy Point of Sale (POS) Prior Authorization Unit (PAU) Provider Enrollment Unit (PEU) CONTACT INFORMATION Molina Medicaid Solutions (877) P.O. Box Baton Rouge, LA Phone: (225) Fax: (225) P.O Baton Rouge, LA Phone: (800) Fax: (800) P.O. Box Baton Rouge, LA Phone: (800) (Toll Free) Phone: (225) (Local) *After hours, please call REVS Molina Medicaid Solutions Prior Authorization P.O. Box Baton Rouge, LA (800) Molina Medicaid Solutions-Provider Enrollment P. O. Box Baton Rouge, LA (225) (225) Fax Page 1 of 4 Frequent Contact Information

25 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: CHAPTER 48: FAMILY PLANNING- TAKE CHARGE PLUS SECTION: FREQUENT CONTACT INFORMATION PAGE(S) 4 Molina Medicaid Solutions (continued) TYPE OF ASSISTANCE Provider Relations Unit (PR) Recipient Eligibility Verification (REVS) CONTACT INFORMATION Molina Medicaid Solutions Provider Relations Unit P. O. Box Baton Rouge, LA Phone: (225) or (800) Fax: (225) Phone: (800) (Toll Free) Phone: (225) (Local) Take Charge Plus Fee Schedule Fee Schedules link then Take Charge Plus Fee Schedule link Department of Health and Hospitals (DHH) TYPE OF ASSISTANCE General Medicaid Hotline Health Standards Section (HHS) Louisiana Children s Health Insurance Program (LaCHIP) Office of Aging and Adult Services (OAAS) CONTACT INFORMATION (888) (Toll Free) P.O. Box 3767 Baton Rouge, LA Phone: (225) Fax: (225) 5292 (225) (Local) (877) (Toll Free) P.O. Box 2031 Baton Rouge, LA Phone: (866) Fax: (225) MedWeb@dhh.la.gov Page 2 of 4 Frequent Contact Information

26 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: CHAPTER 48: FAMILY PLANNING- TAKE CHARGE PLUS SECTION: FREQUENT CONTACT INFORMATION PAGE(S) 4 DHH (continued) TYPE OF ASSISTANCE Office for Citizens with Developmental Disabilities (OCDD) Take Charge Plus Take Charge (Family Planning Waiver) Third Party Liability (TPL) TPL Recovery, Trauma CONTACT INFORMATION 628 N. Fourth Street Baton Rouge, LA Phone: (225) (Local) Phone: (866) (Toll-free) ocddinfo@la.gov P.O. Box Baton Rouge, LA Phone: (888) P.O. Box Baton Rouge, LA Phone: (888) Fax: (877) medweb@la.gov Spanish Town Road Baton Rouge, LA Phone: (225) Fax: (225) Fraud Hotline To report fraud TYPE OF ASSISTANCE CONTACT INFORMATION Program Integrity (PI) Section P.O. Box Baton Rouge, LA Fraud and Abuse Hotline: (800) Fax: (225) Page 3 of 4 Frequent Contact Information

27 LOUISIANA MEDICAID PROGRAM ISSUED: 10/16/14 REPLACED: CHAPTER 48: FAMILY PLANNING- TAKE CHARGE PLUS SECTION: FREQUENT CONTACT INFORMATION PAGE(S) 4 Appeals To file an appeal TYPE OF ASSISTANCE CONTACT INFORMATION Division of Administrative Law (DAL) - Health and Hospitals Section Post Office Box 4189 Baton Rouge, LA (Fax) Other Helpful Contact Information: TYPE OF ASSISTANCE Centers for Medicare and Medicaid Services Office of Population Affairs (OPA) Clearinghouse Southeastrans Transportation Inc. Transportation Call Center U.S. Department of Health and Human Services Sterilization and Consent Forms CONTACT INFORMATION P.O. Box Bethesda, MD Phone: (866) Fax: (866) Info@OPAclearinghouse.org (855) pubs Page 4 of 4 Frequent Contact Information