Family PACT Update

December 2010 | Bulletin 39

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1. Medi-Cal Training Seminars

Mark your calendar for the upcoming Medi-Cal Training Seminar in your area.

Ontario February 16–18, 2011
Fresno April 5–7, 2011

Visit the Training Seminars page for class details.

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2. 340B Drug Pricing Program FAQs

Effective October 1, 2009, covered entities that purchase drugs under the 340B Drug Pricing Program (340B program) shall dispense only 340B program-purchased drugs to Medi-Cal recipients. Providers are also required to bill an amount not to exceed the entity’s actual acquisition cost for the drug as charged by the manufacturer at a price consistent with United States Code, Section 256b, Title 42, plus the professional fee pursuant to Welfare and Institutions Code (W&I Code), Section 14105.45, or the dispensing fee pursuant to W&I Code, Section 14132.01.

Additional Clarification for Covered Entities
The Department of Health Care Services (DHCS) worked with the California Primary Care Association (CPCA) and other 340B entities to identify questions related to the implementation of the 340B program drug-billing requirements. The following Frequently Asked Questions and answers (FAQs) were developed to assist those covered entities:

  1. How does a facility enroll in the 340B program?
    A: Entities that are eligible for enrollment into the 340B program can find detailed information about enrollment on the Health Resources and Services Administration’s Office of Pharmacy Affairs (OPA) Web site.
  2. Our facility is not enrolled in the 340B program. Does the change in the statute now require the facility to be enrolled?
    A: No. An eligible entity may continue to be reimbursed for non-340B program drugs dispensed to Medi-Cal recipients. However, the covered entity will need to maintain documentation that it is not enrolled in the 340B program. If a provider appears on the OPA covered-entity database as a participant, DHCS will consider the provider enrolled in the 340B program. Medi-Cal providers are encouraged to verify that the facility’s information on the OPA database is correct.
  3. When do Medi-Cal providers have to comply with the change in the statute?
    A: Providers were required to comply with the statute October 1, 2009 unless DHCS issued a notice to a specific provider that extended the implementation date.
  4. Our facility does not bill drugs on a Fee-for-Service (FFS) basis, but receives a bundled payment. Is the facility required to use 340B program drugs?
    A: Covered entities do not have to dispense 340B program drugs when a payment is made to a covered entity as part of a bundled, composite or all-inclusive rate. Reimbursement will be based on applicable rates for the services rendered.
  5. Does this change apply to both Medi-Cal FFS and Medi-Cal Managed Care?
    A: The requirement to dispense 340B program drugs applies to the Medi-Cal FFS program and rebate-eligible County Organized Health System (COHS) plans. Reimbursement is based on the applicable contract rates with the individual plans.
  6. What is meant by “actual acquisition cost?”
    A: In determining the actual acquisition cost, DHCS considers any reasonable method utilized by the covered entity to determine the acquisition cost. Acquisition cost can include shipping and handling charges actually incurred by the covered entity in connection with the purchase of 340B program drugs. The covered entity shall reduce its incurred cost by any discounts, rebates, refunds, price reductions or credits actually received by the covered entity and that are directly attributable 340B program drugs. Costs of the covered entity that are incurred during the dispensing of a drug shall not be used to determine the acquisition cost of a drug.
  7. If providers use a contract pharmacy to dispense 340B program drugs, can the contract pharmacy dispense non-340B program drugs to Medi-Cal recipients and bill Medi-Cal FFS directly?
    A: A 340B program contract pharmacy may dispense non-340B program drugs to Medi-Cal recipients even if the beneficiary is considered a “patient” of the covered entity. The pharmacy can bill for such non-340B program drugs under the billing requirements in W&I Code, Section 14105.455. This applies to Medi-Cal FFS and rebate eligible COHS plans. Please review following FAQ #9 for detailed information.
  8. Can a covered entity bill a Medi-Cal Managed Care Plan at a rate higher than the acquisition cost plus a fee?
    A: A covered entity using a 340B program contract pharmacy may arrange with the contract pharmacy to dispense 340B program drugs to Medi-Cal managed care recipients and bill for such 340B program drugs at the contract rate negotiated with the plan (excluding drugs dispensed to members of rebate-eligible COHS plans). Please review following FAQ #9 for detailed information.
  9. Can providers direct all of their patients to a 340B contract pharmacy?
    A: No. Recipients can go to any pharmacy. The official 340B program guidance states:

    “The covered entity health care provider will inform the patient of his or her freedom to choose a pharmacy provider. If the patient does not elect to use the contracted service, the patient may obtain the prescription from the covered entity and then obtain the drug(s) from the pharmacy provider of his or her choice. When a patient obtains a drug from a retail pharmacy other than the entity contract pharmacy, the manufacturer is not required to offer this drug at 340B program pricing.”
  10. Does the statute change require a covered entity to provide 340B drugs to Medi-Cal beneficiaries that are not “patients” of the covered entity?
    A: No. The 340B program has specific rules that allow an entity to provide 340B purchased drugs only to individuals who are considered “patients” of the entity. As noted on the OPA website:

    In summary, an individual is a "patient" of a covered entity (with the exception of State-operated or a funded Acquired Immune Deficiency Syndrome [AIDS] drugpurchasing assistance programs) only if:

    • The covered entity has established a relationship with the individual, such that the covered entity maintains records of the individual's health care, and;
    • The individual receives health care services from a health care professional who is either employed by the covered entity or provides health care under contractual or other arrangements (e.g. referral for consultation) such that responsibility for the care provided remains with the covered entity, and;
    • The individual receives a health care service or range of services from the covered entity which is consistent with the service or range of services for which grant funding or federally qualified health center look-alike status has been provided to the entity. Disproportionate share hospitals are exempt from this requirement.

      • An individual will not be considered a "patient" of the entity for purposes of 340B if the only health care service received by the individual from the covered entity is the dispensing of a drug or drugs for subsequent self-administration or administration in the home setting.

    Therefore, if a Medi-Cal recipient is not a “patient” of the entity according to OPA guidelines, then Medi-Cal does not require the entity to dispense a 340B purchased drug.

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3. Provider Orientation and Update Sessions

Family PACT

Medi-Cal providers seeking enrollment in the Family PACT (Planning, Access, Care and Treatment) Program are required to attend a Provider Orientation and Update Session. Dates for upcoming sessions are listed below. Registration opens at 8 a.m., with Session I beginning promptly at 8:30 a.m.

Individual and group providers wishing to enroll must send a physician-owner to the session. Non-profit and government clinics seeking to enroll must send their medical director, physician or nurse practitioner who is responsible for oversight of medical services rendered at the service site where the provider wants to enroll.

Office staff members, such as clinic managers, billing supervisors and client eligibility enrollment supervisors, are encouraged to attend. However, these staff members are not eligible to receive a Certificate of Attendance. Enrolled clinicians and staff are encouraged to attend to remain current with program policies and services.

Session Format
Family PACT has created a new session format, which offers an option for currently enrolled providers and staff to attend only the afternoon update session, along with either the clinical session or the billing and coding session.

Session I – Overview of the Family PACT Program:

Start Time 8:30 a.m. to 2 p.m.
Instructions Attendance at this presentation is mandatory for clinician providers wishing to enroll in Family PACT and is recommended for other staff who are new to the program or need a refresher.

Note:  The afternoon sessions will run concurrently from 2 p.m. to 4 p.m.

Session II – Clinical Practice Alerts:

Start Time 2 p.m. to 4 p.m.
Instructions Clinicians in attendance who wish to become Family PACT providers must also attend this session. Free continuing education (CE) credit is available for Session II. Providers must bring their medical license number if requesting CE credit; a continuing education request form will be available during onsite registration. Other interested clinical staff are welcome to attend and may request free CE credit for this session.

Session III – Tips for Successful Family PACT Administration:

Start Time 2 p.m. to 4 p.m.
Instructions Administrators and billers interested in Family PACT Program administration and billing information may attend.

Please note the upcoming Provider Orientation and Update Sessions below.

Westin Pasadena
January 6, 2011
8:30 a.m. – 4 p.m.
191 N. Los Robles
Pasadena, CA  91101
(626) 792-2727

For a map and directions to these locations, providers can go to the Family PACT website and click “Directions and Map of Location” for the appropriate session location.

Registration
To register for an orientation and update session, providers should:

Providers with no Internet access may request the registration form by calling 1-877-FAMPACT (1-877-326-7228). Providers must supply the following when registering:

Check-In
Check-in begins at 8 a.m. All orientation sessions start promptly at 8:30 a.m. and end by 4 p.m. At the session, providers must present the following:

Note:  Individuals representing a clinic or physician group should use the clinic or group NPI, not an individual NPI or license number.

Certificate of Attendance
Upon completion of the orientation session, each prospective new Family PACT medical provider will receive a Certificate of Attendance. Providers should include the original copy of the Certificate of Attendance when submitting the Family PACT application and agreement forms (available at the session) to Family PACT Provider Enrollment. Providers arriving late or leaving early will not receive a Certificate of Attendance. Currently enrolled Family PACT providers do not receive a certificate.

Contact Information
For more information about the Family PACT Program, please call 1-877-FAMPACT (1-877-326-7228) or visit the Family PACT website.

The Family PACT Program was established in January 1997 to expand access to comprehensive family planning services for low-income California residents.

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4. Consent Form Required for Essure® Sterilization Services

Providers are reminded that a sterilization Consent Form (PM 330) is always required when billing the following Essure-related sterilization procedure and device:

Additional information is included in the Sterilization section of the appropriate Part 2 Medi-Cal manual.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services Obstetrics 		ster (27)
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5. Family PACT Claim Denial Correction: Estradiol

Claims submitted to the Family PACT (Planning, Access, Care and Treatment) Program for estradiol, billed with HCPCS code Z7610 (miscellaneous drugs and supplies for non-surgical procedure) but without the required secondary diagnosis code (SDC) 626.6 (metrorrhagia), may have been erroneously denied. Providers may not have known the secondary diagnosis code was required because the information was inadvertently left out of the provider manual.

Family PACT providers may rebill claims for estradiol that were denied for the above reasons, who received Remittance Advice Details code 9516: SDC is missing or invalid for the procedure code on their Remittance Advice Details and whose dates of service were August 1, 2006 through December 31, 2009. Timeliness requirements will be overridden. To be considered for reimbursement, resubmitted claims must be received for processing before April 1, 2011.

Note:

Instructions about billing for estradiol with SDC 626.6 were updated in the Family PACT provider manual in January 2010.

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6. Use NPI on POS and in the Transaction Services Area

Providers are strongly encouraged to use their National Provider Identifiers (NPIs) to log on to Transaction Services.

The Transaction Services area on the Medi-Cal website offers access to the following features: Automated Provider Services, Batch Claim Status, Medi-Services, Real Time Internet Eligibility (RTIE), Share of Cost (Spend Down) and allows providers to perform secure transactions. Medi-Cal providers must have a user ID, password and a Medi-Cal POS Network/Internet Agreement on file to log on to Transaction Services.

Additional features are also available on Transaction Services (based on provider enrollment type):

Providers are strongly encouraged to use their NPI in performing Point of Service ( POS) transactions.

The Medi-Cal-supplied POS device is used to verify recipient eligibility, clear Share of Cost liability, reserve Medi-Services, perform Family PACT client eligibility transactions and submit pharmacy or CMS-1500 claims.

For assistance with Internet and POS transactions, please contact the Telephone Service Center (TSC) at 1-800-541-5555.

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7. Use NPI in Secondary Provider Fields

Providers are strongly encouraged to use a valid NPI (National Provider Identifier) in secondary provider fields. This includes fields such as Rendering Provider, Referring Provider, Attending Provider, Admitting Provider and Operating Provider, where applicable. A valid NPI of the inpatient facility where services were rendered is also required in the Service Facility field.

A valid NPI is required in the Referring Provider field when available. If an NPI for the referring provider is not available, a valid license number may be used.

The Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) strongly encourage providers to share their NPI with every entity they work with, such as payers and other providers that may need their NPI for billing purposes. Providers are encouraged to perform the necessary updates to their system and/or billing procedures to include the NPI in the secondary provider fields.

Additional information will be made available to providers in upcoming Medi-Cal Updates and on the Medi-Cal website. The Telephone Service Center (TSC) can also answer questions for providers at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday.

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8. Claim Examples Updated

Examples have been updated for the CMS-1500 and UB-04 claims, including new examples to support recent policy on the Essure ® (hysteroscopic sterilization) micro-inserts.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Family PACT claim cms (7, 11, 13–14); claim ub (11)
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9. Effective Implementation of ICD-10: Part 1 – Planning for Success

By now providers are aware of the upcoming transition to the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) and may be preparing for the October 1, 2013 compliance date. Specific activities depend greatly on the type of provider; for example, a private physician will not have the same level of effort or activities as a group practice or hospital. However, there are basic activities that are consistent across all provider types that, when planned appropriately, can make the effort of migrating to the new code sets a little easier. Here are four areas that can be started today which will provide a foundation for a successful implementation of ICD-10.

  1. Establish an ICD-10 Team – This can also be referred to as an ICD-10 Executive Steering Committee depending on the size and complexity of an organization. A knowledgeable team of health information managers, coders, clinicians and information technology experts can provide the necessary collaborative environment to address an organization’s specific needs and issues. Responsibilities should include:
    • Designating a lead expert who can act as the project manager.
    • Identifying and prioritizing necessary activities.
    • Establishing regular and frequent meetings.
    • Communicating plans to office/organization staff.

    The Centers for Medicare & Medicaid Services (CMS), American Health Information Management Association (AHIMA), and the Workgroup for Electronic Data Interchange (WEDI) have information and tools available to the public. AHIMA has developed an ICD-10 Preparation Checklist and an ICD-10 Readiness and Assessment Tool that can be downloaded from the Preparing for ICD-10 site. CMS has also published some basic steps for providers to prepare for ICD-10 which can be viewed on the ICD-10 Provider Resources webpage.

  2. Education and Training – Education and training includes awareness through in-depth instruction. Due to the changes and increased complexity of the ICD-10, education and training is critical. The HIPAA Final Rule indicates that 50 hours of training will be needed for both the Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) sections. Since not all providers use the ICD-10-PCS, the number of hours needed for
    ICD-10-CM is estimated at 16 according to AHIMA. However, these estimates assume that coding professionals currently possess the necessary level of knowledge in the biomedical sciences (anatomy, physiology, pathophysiology, pharmacology and medical terminology) in order to correctly identify and apply ICD-10-CM and PCS codes. In developing an education and training approach, take into consideration:
    • Assessment of billing and coding staff for strengths and/or weaknesses in the biomedical sciences.
    • Review of the fundamentals of ICD-10-CM and PCS, including the Final Rule.
    • Refresher courses in the biomedical sciences, if needed.
    • Begin studying root operations and approaches in ICD-10-PCS (inpatient coding only).
    • Review of the General Equivalence Mappings (GEM) published by CMS.

    The Final Rule and GEMs can be downloaded from the ICD-10 Overview webpage. AHIMA has developed role-based education and training steps that can be viewed at Role-Based Model for ICD-10 and includes AHIMA recommended activities and resources for inpatient and outpatient coders and data managers.

  3. Vendor Considerations – Communication with vendors is critical and should start early and continue on a regular and frequent basis throughout the transition. Here are a few things to consider when communicating with vendors:

    • Does the vendor have fully functional, compliant products and services which will be available ahead of the compliance date to allow thorough ICD-10 testing?
    • When will upgrades or new systems be available for testing and implementation?
    • Are there any system upgrades/replacements needed to accommodate ICD-10?
    • How will the products accommodate both ICD-9 and ICD-10 as needed for services provided before and after the compliance date?
    • What are the costs involved with upgrades and are they covered by existing contracts?
    • What kind of training and customer support, such as avoiding potential reimbursement issues, will the vendor provide?
  4. Implementation Timeline – A high-level timeline for implementing ICD-10 was published in the Final Rule. However, it focuses only on the publishing of the Final Rule, initial implementation activities and the compliance date. While it’s short on details, the industry has stepped up to fill in the gaps. Based on communications from CMS, AHIMA and WEDI, a recommended timeline for ICD-10 compliance can be established.
 
Activity Timeline
Education & Training January 2009 – November 2013
Planning & Assessment August 2010 – January 2011
Implementation Activities (gap analysis,
design, development, internal testing) 		January 2011 – January 2013
External Testing January 2013 – September 2013
Compliance Date October 1, 2013

Adhering to timelines in conjunction with the activities described will ensure a timely and smooth transition to ICD-10. Awareness, communication, preparation and collaboration are the key to a successful ICD-10 transition.

For more information providers may visit:

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10. Sterilization Consent Forms Order Instructions Update

Providers are reminded that copies of the sterilization Consent Form (PM 330) can be downloaded (in English and Spanish) from the Forms page of the Medi-Cal website or ordered by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Providers must supply their NPI number when ordering the form(s). The following information also may be requested:

 This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Family PACT prov res (7)
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics 		ster (8, 18-19)
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