2018-30: Diagnosis Code Requirements for Phosphodiesterase-5 Enzyme Inhibitors
Date: 05/23/18
Effective June 1, 2018, the Louisiana Medicaid Drug Utilization Review (LADUR) Program will implement POS edits for diagnosis code requirements for select phosphodiesterase-5 enzyme inhibitors. As a reminder, the LADUR program includes Fee-For-Service (FFS) and Managed Care Organizations (MCOs).
Phosphodiesterase-5 Enzyme Inhibitors
Pharmacy claims for select phosphodiesterase-5 enzyme inhibitors require submission of a diagnosis code at POS. Acceptable diagnosis codes are indicated in the complete notice from the Louisiana Department of Health. Please click here to review the complete notice.
Please note: Louisiana Medicaid does not currently pay for a diagnosis of erectile dysfunction (ED).
Denial Codes
Pharmacy claims for select phosphodiesterase-5 enzyme inhibitors billed without an acceptable diagnosis code will deny with NCPDP Reject Code 38 (Missing or Invalid Diagnosis Code).
When the prescribing practitioner does not indicate a diagnosis code on the prescription and when the prescriber cannot be reached, a denial for a missing diagnosis code may be overridden if the pharmacist determines that the recipient cannot wait to receive the medication.
The pharmacist may override the denial by entering "03" in NCPCP field 418-DI (Level of Service) specifying an emergency.
Questions?
If you have questions about the content of this memo, you may contact the FFS pharmacy help desk by phone at (800) 437-9101.
If you have questions about pharmacy claims billing, you may contact the appropriate plan and their pharmacy help desk listed below.
| HEALTH PLAN | PHARMACY HELP DESK | PHONE NUMBER |
|---|---|---|
| Aetna | CVS Health | (855) 364-2977 |
| AmeriHealth Caritas | PerformRX | (800) 684-5502 |
| Fee for Service | Molina | (800) 648-0790 |
| Healthy Blue | Express Scripts | (844) 367-6111 |
| Louisiana Healthcare Connections | CVS Caremark | (800) 311-0543 |
| United Healthcare | Optum RX | (866) 328-3108 |