Medi-Cal Update
Clinics and Hospitals | July 2019 | Bulletin 538Print Medi-Cal Update
The Department of Health Care Services (DHCS) California Medicaid Management Information System (MMIS) Division is engaged in a multi-year initiative to transition contracts for the Fiscal Intermediary (FI) responsible for the business operations of fee-for-service Medi-Cal.
The transition from the current vendor to the incoming FI, DXC Technology Services, LLC, shall occur on October 1, 2019, with a primary objective being a successful transition without disruptions to state programs, providers or beneficiaries.
As part of our commitment to keeping the provider community informed throughout this process, DHCS began releasing Frequently Asked Questions on the Medi-Cal website. The first round of FAQs was released in a previously published NewsFlash article titled “Fiscal Intermediary Frequently Asked Questions” The following questions and answers are a continuation of this effort.
FI Transition FAQs:
Is Medi-Cal making any changes to Computer Media Claims (CMC)/electronic claim submissions or electronic attachments with the transition to the new FI on October 1, 2019?
No. Medi-Cal is not making any changes to electronic claims or attachment submission requirements prior to October 1, 2019. Providers and/or submitters are not expected to reapply or retest as part of the vendor transition.
Is Medi-Cal making any changes to the hours of operation for any of the provider or member support areas?
All areas, with one exception, are retaining the same hours of operation for provider and member support. Effective October 1, 2019, the hours of operation for the Point of Service (POS) Helpdesk/ Internet Help Desk is 8 a.m. to 5 p.m., Monday through Friday, except holidays. Providers and submitters may need to update business or operational practices to align with this change.
Will I need to submit my applications via a different portal from the Provider Application and Validation for Enrollment (PAVE)?
No. If you currently enroll through PAVE, you will continue to enroll through PAVE. The transition to a new vendor does not impact provider enrollment processes or the PAVE provider enrollment portal PAVE.
Will my current provider ID numbers change once the transition occurs?
No. The transition will have no impact on provider ID numbers; current provider ID numbers will not change once the transition occurs. Additionally, Provider Identification Numbers (PINs) will not change.
Will my application be fully processed if I am already in the enrollment process during the transition?
The transition will have no impact on the provider enrollment process, or providers who are in the enrollment process during the transition.
How will I be notified of further changes?
Updates about the transition will be posted on the Medi-Cal website.
To receive personalized email notifications with links to the most up-to-date information, providers may subscribe to the Medi-Cal Subscription Service (MCSS) MCSS Subscriber Form on the Medi-Cal website.
Effective for dates of service on or after July 1, 2019, the following HCPCS codes are Medi-Cal benefits:
| HCPCS Code | Description |
| C7956 | Fluorescence lymph map with indocyanine green (ICG) |
| J9030 | Injection, BCG live intravesical installation, 1 mg |
| J9036 | Injection, bendamustine HCI (Belrapzo), 1 mg |
| J9356 | Injection, trastuzumab, 10 mg and hyaluronidase-oysk |
| Q5112 | Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10mg |
| Q5113 | Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg |
| Q5114 | Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg |
| Q5115 | Injection, rituximab-abbs, biosimilar, 10mg |
Additionally, policy for HCPCS code J9355 (injection, trastuzumab, 10 mg) is updated.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug a-d (9); chemo drug p-z (10, 11, 23–25); inject cd list (3, 4, 6, 15) |
| Chronic Dialysis Clinics Obstetrics Pharmacy Rehabilitation Clinics |
inject cd list (3, 6, 14, 15) |
The new EPSDT provider manual section is available to help providers understand the scope of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
EPSDT
EPSDT services are a benefit of the Medi-Cal program as specified in Title XIX of the Social Security Act (SSA), Section 1905(r)(5) [Title 42 of the United States Code, Section 1396d(r)]. The benefits covered under EPSDT provide comprehensive and preventive health care services for individuals under 21 years of age who are enrolled in Medi-Cal. These services are key to ensuring that children and youth receive appropriate preventive medical, dental, vision, hearing, mental health, substance use disorder, developmental and specialty services, as well as all necessary services to address any defects, illnesses or conditions identified.
Medical Necessity
The standards to meet medical necessity differ between Medi-Cal and EPSDT. The EPSDT standard is as follows:
This information is reflected in the following provider manual(s):
Effective for dates of service on or after February 12, 2019, and consistent with the U.S. Preventive Services Task Force recommendation, Medi-Cal will now reimburse individual and/or group counseling sessions for pregnant or postpartum women with certain depressive, socioeconomic and mental health related risk factors. These risk factors include perinatal depression, a history of depression, current depressive symptoms (that do not reach a diagnostic threshold), low income, adolescent or single parenthood, recent intimate partner violence, elevated anxiety symptoms and a history of significant negative life events.
Up to a combined total of 20 individual counseling (CPT codes 90832 and 90837) and/or group counseling (CPT code 90853) sessions are reimbursable when delivered during the prenatal period and/or during the 12 months following childbirth. Modifier 33 must be submitted on claims for counseling given to prevent perinatal depression.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
preg early (2); preg post (4); prev (8) |
| Home Health Agencies/Home and Community-Based Services Inpatient Services |
preg post (4) |
| Obstetrics | preg early (2); preg post (4) |
| Psychological Services | psychol (1, 3, 4, 9) |
A previous Medi-Cal Update article titled “Prenatal Care for Medi-Cal Recipients with OHC is Subject to Cost Avoidance” that published on December 14, 2018, stated that prenatal care services claims for Medi-Cal recipients with Other Health Coverage (OHC) are cost avoided. The following expands on existing criteria for cost avoidance of these claims.
Prior to the Bipartisan Budget Act of 2018, prenatal care services were subject to the optional “pay and chase” method for claim reimbursement. Under the “pay and chase” method, if Medi-Cal reimbursed a service provided to a recipient who also had OHC, Medi-Cal may have attempted to bill the OHC to cover part or all of what Medi-Cal has paid on the claim. This method included claims reimbursed under the global maternity services billing option when prenatal care services could not be differentiated from labor, delivery and postpartum care.
In accordance with the Bipartisan Budget Act of 2018, Section 53102, all prenatal care services are subject to cost avoidance. In addition, any “pay and chase” claim that is bundled with prenatal care services will result in the entire claim being cost avoided.
Standard coordination of benefits will continue to occur for all claims submitted.
A recipient is required to use their OHC prior to their Medi-Cal coverage when the same service is available under the recipient’s OHC. When a service or procedure is not a covered benefit of the recipient’s OHC, a copy of the original denial letter or Explanation of Benefits (EOB) is acceptable for the same recipient and service for a period of one year from the date of the original denial letter or EOB.
In June 2019, the new Diabetes Prevention Program (DPP) Part 2 provider manual section was released, which listed incorrect month numbers in the descriptions for HCPCS codes G9877 and G9883. The corrected descriptions are as follows:
HCPCS| Code | Description |
| G9877 | Two DPP core maintenance sessions were attended by a DPP recipient in months 10-12, and the recipient did not achieve the minimum 5 percent weight loss |
| G9883 | Two DPP core maintenance sessions were attended by a DPP recipient in months 16-18, and the recipient did not achieve the minimum 5 percent weight loss |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine Home Health Agencies/Home and Community-Based Programs Obstetrics |
diabetes (6, 7) |
Effective for dates of service on or after July 1, 2017, HCPCS code J9299 (injection, nivolumab, 1 mg) is reimbursable for recipients 12 years and older.
In addition, treatment indications for nivolumab are expanded. Providers are reminded that an approved Treatment Authorization Request (TAR) is required for reimbursement, and must include clinical documentation demonstrating the following:
No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug e-o (23, 24) |
Effective retroactively for dates of service on or after April 1, 2017, the reimbursement rates for radiology services are adjusted.
The rates adjustment will be implemented on July 22, 2019, but will not appear on the Med-Cal rates website until August 15, 2019.
An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. No action is required of Medi-Cal providers.
Effective for dates of service on or after August 1, 2019, one of the following ICD-10-CM diagnosis codes is required for reimbursement of HCPCS code J2357 (omalizumab, injection, 5 mg):
In addition, the age requirement is updated to 6 years and older.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject drug n-r (4–6) |
Effective for dates of service on or after August 1, 2019, the ICD-10-CM diagnosis code requirement is updated for HCPCS code J2326 (injection, nusinersen, 0.1 mg). The required codes are now only ICD-10-CM diagnosis code G12.0 (infantile spinal muscular atrophy, type I [Werdnig-Hoffman]) or G12.1 (other inherited spinal muscular atrophy). Indications, dosage and authorization requirements for nusinersen are also updated.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Rehabilitation Clinics Pharmacy |
inject drug n-r (2, 3) |
A previous article that published in the April 2019 Medi-Cal Update titled “Hospice Eligibility Billing and Payment Requirements for Board and Care” incorrectly included the recipient’s physician in the list of those who can sign the hospice election form. The corrected article follows:
Hospice providers are reminded that once a recipient has made the decision to elect, revoke or re-elect participation in the hospice program, the provider is required to complete and submit the hospice notification of election statement to the Hospice Unit of the Medi-Cal Eligibility Division in the Department of Health Care Services (DHCS). The hospice election form cannot be processed by DHCS unless it is signed by the recipient or the recipient’s authorized representative. By choosing hospice election, the recipient will receive certain services as specified in the Hospice Care section in the appropriate Part 2 provider manual. Providers should send all forms to the address below:
Attn: Hospice ClerkHospice providers are also reminded of the binding federal regulations and the requirement to accept responsibility for the management, billing and payments associated with hospice services in a long term care (LTC) setting (room, board and hospice service). The federal regulations further describe the requirements for a hospice plan of care and criteria for participation in providing hospice services within an LTC setting, and are located in:
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals Hospice Care Program Inpatient Services General Medicine |
hospic (2) |
The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.
| Additions, Effective July 1, 2019 | |
| NDC Labeler Code | Contracting Company’s Name |
| 68418 | BIOCODEX, INC. |
| 69853 | PORTOLA PHARMACEUTICALS, INC. |
| 71403 | EPI HEALTH, LLC |
| 72508 | NEOPHARMA INC. |
| 72512 | AVERITAS PHARMA, INC. |
| 72721 | HEARTWOOD PHARMA |
| 72733 | SANOFI US CORPORATION |
| Terminations, effective July 1, 2019 | |
| NDC Labeler Code | Contracting Company’s Name |
| 16477 | LASER PHARMACEUTICALS, LLC |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Adult Day Health Care Centers AIDS Waiver Program Chronic Dialysis Clinics Clinics and Hospitals Expanded Access to Primary Care Program General Medicine Heroin Detoxification Home Health Agencies/Home and Community-Based Services Hospice Care Program Multipurpose Senior Services Program Obstetrics Pharmacy Rehabilitation Clinics |
drugs cdl p5 (7, 17, 18, 20, 21) |
Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (ยง) 24005(k). The Provider Orientation training is delivered online and in person and includes information on comprehensive family planning, program benefits and services, client eligibility, provider responsibilities and compliance.
Each provider’s service location is required to be certified for enrollment in the Family PACT Program. Applicants who are enrolled in Medi-Cal in good standing and have submitted a Family PACT application packet may complete the Provider Orientation to certify a site for enrollment.
Each service location must designate one eligible representative to be the site certifier. The site certifier cannot certify multiple sites.
The medical director, physician, certified nurse practitioner or certified nurse midwife who is responsible for overseeing the family planning services rendered at the location to be enrolled is eligible to certify the site.
Provider Orientation details are posted on the Family PACT website at www.familypact.org and registration information can be found on the Family PACT Learning Management System (LMS) website at www.ofpregistration.org.Upcoming In-Person Orientations
| Sacramento August 7, 2019 9:00 a.m. – 1:00 p.m. Sierra Health Foundation 1321 Garden Highway Sacramento, CA 95833 |
Oakland September 17, 2019 10:00 a.m. – 2:00 p.m. Oakland Endowment 2000 Franklin Street Oakland, CA 94612 |
If there are any questions regarding the orientation process, providers may contact the Office of Family Planning at (916) 650-0414 or send an email to ProviderServices@dhcs.ca.gov.
The August Medi-Cal provider seminar is scheduled for August 14 - 15, 2019, at the Long Beach Marriott in Long Beach, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.
Throughout the year, the Department of Health Care Services (DHCS) and the California Medicaid Management Information System (CA-MMIS) Fiscal Intermediary (FI) for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:
Providers must register by July 31, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 31, 2019, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web page of the Medi-Cal website.
Note:Wi-Fi will not be provided at the seminar. Please plan accordingly.
Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.
Providers may also schedule a custom billing workshop. On the Lookup Regional Representative web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.
Providers are encouraged to bookmark the Provider Training web page and refer to it often for current seminar information.
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