Medi-Cal Update

General Medicine | January 2015 | Bulletin 487

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1. DHCS and Providers Team for Rollout of CA-MMIS Replacement System

The Department of Health Care Services’ (DHCS) partnership with the provider community ensures accessible and affordable quality health care services for Californians. To further this effort, development and implementation of a CA-MMIS replacement system, referred to as CA-MMIS Health Enterprise (HE), is underway.

DHCS’ strategic plan leverages Health Information Exchange and Health Information Technologies to improve health care effectiveness and efficiency for program beneficiaries. The new CA-MMIS HE system will enhance Medi-Cal program automation, standardization and interoperability.

DHCS is excited to begin this much-awaited transition to a more streamlined and integrated system. The robust HE technology is only one piece of the project’s success, however. DHCS will focus on helping providers transition to the new system by working together to support people and processes. The new technology and processes will provide business value and improvements to customers (end-users, providers, beneficiaries) while enabling new levels of Medicaid Information Technology Architecture (MITA) business maturity.

The multi-year HE transition takes advantage of similar systems used in other states. The existing CA-MMIS system will be gradually replaced over several major releases. DHCS designed the releases to adhere to federal MITA technology standards, which will allow the state to maximize federal funding opportunities. HE’s business operation will transition gradually, providing additional capabilities and finally supporting all the various Medi-Cal programs.

Release 1
Deployed in December 2014
This established the infrastructure and initial platform for MITA-conforming system design. Release 1 also established the online portal, providing HE’s primary access point.

Release 2
Planned for mid 2015
This implements functionality for end-to-end claims processing, HE’s primary purpose. Child Health and Disability Prevention Program (CHDP) providers will be notified and supported as they prepare for the first wave of claims-related changes. System access, business process changes and training will be rolled out in the months to come, in preparation for going live in the summer of 2015.

Release 3
Planned for end of 2015
This implements expanded functionality for pharmacy authorizations, claims processing and related processes. A variety of other Medi-Cal programs and associated claims processes will be included. Again, DHCS will support impacted providers to be ready for these changes.

Release 4
Planned for mid 2016
This implements functionality for a variety of other Medi-Cal programs and their associated claims, medical authorizations and related processes.

Release 5
Planned for end of 2016
This implements functionality to process Medi-Cal claims, which constitute the major claims processing workload. The release will also incorporate any remaining functionality to fully implement HE.

Through the coming weeks and months, providers should watch for updates and news about the HE system in Medi-Cal Update bulletins and the Medi-Cal website’s NewsFlash area to anticipate changes that will affect their business. To this end, providers are strongly encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive up-to-the-minute notifications related to the HE implementation. These notifications will inform and prepare providers to minimize unnecessary service disruptions. Providers may sign up for MCSS by completing the MCSS Subscriber Form on the Medi-Cal website.

DHCS looks forward to collaborating with its provider community to embrace and realize the benefits of the new system in 2015 and beyond.

Providers with questions or concerns may call the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, except holidays.

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2. RTD Form Completion for ICD Indicator Errors

The Resubmission Turnaround Document (RTD) (Form 65-1) completion instructions are updated to illustrate how RTDs are completed for Payment Request for Long Term Care (25-1) claims that were submitted with incorrect or missing ICD indicators.

In the Correct Information field of the RTD form, providers submit the correct ICD indicator and diagnosis code information on separate lines, as follows:

RTD Form Completion for ICD Indicator Errors

F.I. Use Only Field
The Field box identifies a claim field.

Correct Information Field

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

Provider Manual(s) Page(s) Updated
Part 2 resub comp (4, 5)
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3. ICD-10 Beta Testing Results

Medi-Cal recently completed ICD-10 beta testing with selected provider and submitter participants. The beta testing validated participants’ practice electronic files for claims containing ICD-10-CM and ICD-10-PCS codes and the readiness of the Medi-Cal claims processing system to successfully process ICD-10 coded electronic claims.

Participants
Thirty Medi-Cal submitters completed testing with Medi-Cal. The group of participants included the following types of providers:

Submissions also included test claims from clearinghouses and billing services.

Test Scenarios
Testing focused on electronic claims which included Professional (837P), Institutional (837I) Inpatient/Long-Term Care (LTC) and Institutional (837I) Outpatient claims. Test scenarios included both valid claim submissions and invalid claim submissions.

Medi-Cal reviewed the adjudication status for all test claims and communicated the status back to the submitters for validation.

Results
Participants submitted a total of 119 files representing the following claim types:

All tests passed with expected results.

Conclusion
Medi-Cal did not identify any issues with the ICD-10 code business rules in the system as a result of the beta testing effort.

Future Provider Readiness Testing
Medi-Cal is in the process of defining additional provider readiness testing to take place in 2015. Requests for participants will be made in future Medi-Cal and Family PACT Update bulletins and announced via other communication methods, as appropriate.

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4. Updated Rate for Medroxyprogesterone Acetate Injection for Contraceptive Use

Effective retroactively for dates of service on or after October 1, 2014, the rate for HCPCS code J3490 (unclassified drugs) when billed with modifier U8 (medroxyprogesterone acetate [150 mg]) for contraceptive use has been updated from $72.63 to $72.11, which includes a one-time administration fee of $4.46.

No action is required of Medi-Cal and Family PACT providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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5. MLTSS Transition to Managed Care Payment for Services

In Los Angeles, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara counties, Medi-Cal beneficiaries, including dual-eligible beneficiaries who have opted out of Cal MediConnect or who are not eligible for Cal MediConnect, are required to join a Medi-Cal Managed Care Plan (MCP) to receive Medi-Cal benefits. This includes Managed Long Term Supports and Services (MLTSS) and Medicare wrap-around benefits.

MLTSS benefits include In-Home Support Services, Multipurpose Senior Services Program, Community-Based Adult Services and Long Term Care (LTC). In 2015, required enrollment will begin in Orange County.

While providers will need to contract with an MCP to be reimbursed for beneficiaries in Cal MediConnect, providers do not have to contract with an MCP to receive Medi-Cal reimbursement for patients in fee-for-service Medicare or a Medicare Advantage plan. In these cases, a provider can bill a patient’s MCP to cover 20 percent of the treatment cost even if there is no contract with the plan.

To validate a patient’s eligibility, providers can check the Medicare eligibility system and Medi-Cal eligibility systems via the Automated Eligibility Verification System (AEVS) to verify that the patient has an active or pending enrollment in either a Cal MediConnect or Medi-Cal MCP.

Payment for the Care Provided to Cal MediConnect Beneficiaries
Under Cal MediConnect, providers will see streamlined administration. They will be able to submit claims to one plan rather than having to navigate both the Medicare and Medi-Cal billing process. Some physicians may receive monthly capitation payments while some may bill fee-for-service depending on the arrangement they have with the Cal MediConnect plan or its delegate. If there are any questions on billing and payments regarding services rendered to a beneficiary in a Cal MediConnect plan, the provider may refer to their contract with the plan or contact the plan’s provider services.

Beneficiaries Not Enrolled in a Cal MediConnect Plan
Dual eligible beneficiaries may choose to receive their Medicare services outside of Cal MediConnect. Billing and payment to Medicare for these services will be the same as in the past.

Medicare should be billed and will pay 80 percent of the Medicare fee schedule. By law, the 20 percent copay cannot be billed to dual-eligible patients (Welfare and Institutions Code [W&I Code], Section 14019.4).

In most cases, providers will need to send their crossover claims (claims billed to Medi-Cal for Medicare deductible and coinsurance) for the 20 percent copay to the beneficiary’s Medi-Cal plan, which will pay the physician any amount owed under state law regarding Medi-Cal. In some cases, Medicare will send crossover claims directly to the Medi-Cal plans. Physicians do not need to be part of the Medi-Cal plan’s network to have these crossover claims processed and reimbursed.

It should be noted, however, that state law limits Medi-Cal’s reimbursement on Medicare claims to an amount that, when combined with the Medicare payment, does not exceed Medi-Cal’s maximum allowed for similar services, (W&I Code, Section 14109.5). This means that if the Medi-Cal rate is 80 percent or less of the Medicare rate for the service rendered, Medi-Cal will not reimburse anything on these crossover claims. This has been state law for over 30 years.

Since Medi-Cal reimbursements are generally lower than Medicare reimbursements, Medi-Cal will owe reimbursement for only a few services on Medicare claims.

If a patient receives Medicare through fee-for-service, but is required to enroll in a Medi-Cal plan for Medi-Cal benefits, this does not affect the patient’s ability to continue to see his or her Medicare fee-for-service physician.

Medi-Cal plans are assuming many of the administrative functions formerly performed by the California Department of Health Care Services (DHCS) on fee-for-service claims. This includes processing and paying Medicare/Medi-Cal crossover claims for which the state has liability. Again, physicians need not be part of the Medi-Cal MCP network to be reimbursed for these claims.

The primary role of these Medi-Cal MCPs for dual eligibility is to administer Medi-Cal benefits such as LTC, non-emergency medical transportation and other supports and services not covered by Medicare. Providers need not contract with the Medi-Cal plan to provide authorization for medical transportation or other Medi-Cal services.

Physician Reimbursement for Medicare Services is Not Affected by Enrollment in Medi-Cal MCP
As noted above, dual-eligible beneficiaries outside of Cal MediConnect are required to enroll in a Medi-Cal MCP to receive Medi-Cal benefits (primarily MLTSS). Beneficiaries who are eligible for both programs receive physician services under Medicare, not Medi-Cal. There is no impact on physician services or reimbursement because Medicare is still the primary payer. The beneficiary must enroll in a Medi-Cal MCP. That the patient is enrolled in the plan has no impact on the physician services or reimbursement under Medicare.

Under MLTSS, providers (including non-physician providers) must bill Medicare for Medicare services (whether Medicare Advantage or fee-for-service) and bill Medi-Cal for the Medi-Cal services. Medicare will remain the primary payer and the Medi-Cal plan the secondary payer.

Providers who experience claims payment issues with a Medi-Cal MCP may contact the Department of Managed Health Care (DMHC) Provider Complaint Unit. Providers have the right to report to DMHC instances in which the provider believes a Medi-Cal MCP has engaged in an unfair payment pattern. Before submitting a report to the DMHC, providers must first participate in the Medi-Cal MCP’s Provider Dispute Resolution process. If a provider completes this process without resolution, a provider may submit a report to the DMHC through the Provider Complaint System Login page of the DMHC website. Forms and instructions for the provider reporting process may be found on the Provider Complaint Against a Plan page of the DMHC website.

For more information on Cal MediConnect and MLTSS, visit the Physician Toolkit page and the Providers page, both on the CalDuals website.

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6. 2015 CPT-4 and HCPCS Codes Not Yet Adopted

The 2015 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) Level II codes will become effective for Medicare on January 1, 2015. Medi-Cal, Every Woman Counts (EWC) and the Family PACT (Planning, Access, Care and Treatment) Program have not yet adopted the 2015 CPT-4 and 2015 HCPCS updates.

Providers should not use the 2015 codes to bill for Medi-Cal, EWC and Family PACT services until notified to do so in a future Medi-Cal Update.

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7. Annual Hospice Care Medi-Cal Rates Update

The Department of Health Care Services (DHCS) has updated the reimbursement daily and hourly rates for hospice providers. Effective for dates of service on or after October 1, 2014, providers should bill using the new hospice care rates. For an updated list of rates, providers may visit the Long Term Care Reimbursement page of the DHCS website.

Providers do not need to resubmit claims. Xerox State Healthcare, LLC (Xerox) will process any retroactive rate adjustments for claims paid at the old rate for services on or after October 1, 2014.

For billing or payment questions, providers should contact the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday.

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8. Prenatal Care: Medi-Cal Focuses on Tdap for Pregnant Women

Effective for dates of service on or after August 1, 2014, Medi-Cal policy for CPT-4 code 90715 (tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], when administered to individuals 7 years or older, for intramuscular use) is aligned with the most recent recommendations from the Advisory Committee on Immunization Practices (ACIP). The new portion of the policy follows:

Providers of prenatal care must implement a Tdap immunization program for all pregnant women. Health care personnel should administer a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation, although Tdap may be given at any time during pregnancy.

For more information, refer to the Morbidity and Mortality Weekly Report (MMWR) page of the Centers for Disease Control and Prevention website.

Instructions for billing with code 90715 are not changing. A sample CMS-1500 claim follows:

Billing with code 90715 on a sample CMS-1500

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

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Pharmacy
immun (16)
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9. CPT-4 Code 81479 Available for Billing of NIPT for Fetal Aneuploidy

Effective for dates of service on or after February 1, 2015, providers may bill for noninvasive prenatal testing (NIPT) for fetal aneuploidy with either CPT-4 code 81479 (unlisted molecular pathology procedure) or CPT-4 code 81507 (fetal aneuploidy [trisomy 21, 18 and 13] DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (28)
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10. Incontinence Supplies Product Lists Converting to Excel Format

To improve access to the lists of contracted incontinence supply products, the current lists provided in Microsoft Word format will be converted to Microsoft Excel format in a future Medi-Cal Update. To accommodate the conversion, the Incontinence Medical Supplies: An Overview section of the Part 2 provider manual, which will be renamed Incontinence Medical Supplies, will include hyperlinks to the following lists:

The List of Contracted Incontinence Absorbent Products will list the contracted disposable adult and youth size briefs/diapers, adult size protective underwear/pull-ons, belted undergarments, shields, liners, pads and reusable underwear.

The Incontinence Medical Supplies section of the Part 2 provider manual will also include information about program coverage, authorization, Code 1 and documentation requirements and reimbursement. Additionally, this provider manual will include a list of contracted and non-contracted Medi-Cal incontinence HCPCS billing codes and a list of contractors.

The Incontinence Medical Supplies Example: CMS-1500 and Incontinence Supplies Prescription Form: Completion sections of the Part 2 provider manual will also be revised. The Incontinence Supplies Prescription Form itself will not change. All other incontinence supply sections of the Part 2 provider manual will be removed.

Please continue to refer to Medi-Cal Update for further information regarding this conversion.

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11. Medi-Cal List of Contract Drugs I

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs.

A summary of drugs that have been changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s)Updated
January 1, 2015 ASENAPINE Restriction added drugs cdl p1a (16)
January 1, 2015 DORZOLAMIDE HCL AND TIMOLOL MALEATE Restriction added drugs cdl p1a (63)
January 1, 2015 RIVAROXABAN Restriction removed drugs cdl p1c (42)
March 1, 2015 CAPECITABINE Restriction added drugs cdl p1a (29)
March 1, 2015 NILUTAMIDE Restriction added drugs cdl p1c (5)
April 1, 2015 BORTEZOMIB Restriction added drugs cdl p1a (23)
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12. Medi-Cal List of Contract Drugs II

The following provider manual section has been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs.

A summary of the drug that has been changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
December 1, 2014 BUPRENORPHINE/ NALOXONE Administration added, restriction deleted, restrictions added drugs cdl p1a (26)
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13. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective January 1, 2015
NDC Labeler Code Contracting Company’s Name
10544 BLENHEIM PHARMACAL, INC.
49730 HERCON PHARMACEUTICALS, LLC
51021 SIRCLE LABORATORIES, LLC
55607 HEALTH SCIENCE FUNDING, LLC
55724 ANACOR PHARMACEUTICALS
58463 PRAGMA PHARMACEUTICALS, LLC
58657 METHOD PHARMACEUTICALS
59385 BIODELIVERY SCIENCES INTERNATIONAL, INC.
59617 GREER LABORATORIES, INC.
59922 KERYX BIOPHARMACEUTICALS, INC.
62034 BLENHEIM PHARMACAL, INC.
68628 DISCOVERY LABORATORIES, INC.
69238 AMNEAL PHARMACEUTICALS, LLC

Terminations, effective January 1, 2015
NDC Labeler Code Contracting Company’s Name
11523 SCHERING HEALTHCARE PRODUCTS
49614 MEDICINE SHOPPE INTERNATIONAL, INC.
66213 PBM PHARMACEUTICALS, INC.
68016 CHAIN DRUG CONSORTIUM, 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 (6, 10, 12–15, 17, 18)
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14. Select Target Drugs Updated for Manual Drug Use Review

The list of select target drugs for pharmacists performing manual Drug Use Review (DUR) has been updated in DUR Appendix C: Criteria and Standards Summary section of the Medi-Cal Drug Use Review Manual.

Added Drug(s)
Abacavir Efavirenz Norethindrone/ Ethinyl
Acyclovir Emricitabine Estradiol
Amantidine Estradiol Valerate/ Norethindrone/
Aminophylline    Dienogest Mestranol
Aripiprazole Ethacrynate Norgestimate/ Ethinyl
Azithromycin Ethinyl Estradiol/ Estradiol
Cefaclor    Drospirenone Norgestrel/ Ethinyl
Cefadroxil Ethynodiol/ Ethinyl Estradiol
Cefixime    Estradiol Prochlorperazine
Cephalexin Fluconazole Promethazine
Chlorothiazide Ipratropium Rilpivirine
Chlorpromazine Isoniazid Ritonavir
Clarithromycin Levonorgestrel/ Ethinyl Sulfamethoxazole
Clindamycin    Estradiol Tenofovir
Cromolyn Lorazepam Testosterone
Desogestrel/ Ethinyl Methylphenidate Zidovudine
Estradiol Metronidazole Ziprasidone
Diazepam Nitrofurantoin  
Diphenox – Atropine Norethindrone  

Removed Drug(s)
Furosemide    
Metformin    
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15. Alert: Folic Acid Awareness Week is January 4th – 10th, 2015

Drug Use Review - Educational Information

Research has shown that a daily intake of 0.4mg (400 μg) of folic acid prior to conception can reduce the risk of having an infant born with a neural tube defect (NTD) such as spina bifida or anencephaly by approximately 80%.1 Both the United States Public Health Service and the Centers for Disease Control and Prevention (CDC) recommend that all women between 15 and 45 years of age should consume 0.4 mg folic acid daily because half of all U.S. pregnancies are unplanned, and these birth defects occur very early in pregnancy (three to four weeks after conception), before most women know they are pregnant.2

Trends in folic acid supplement intake among all women of reproductive age in California indicate that although the overall prevalence of intake of supplements containing folic acid remained stable between 2002(40%) to 2006(41%), use decreased among Hispanic women and women with less education during this same period.3

Within the Medi-Cal fee-for-service program the rate is much lower, with only 9% of female Medi-Cal fee-for-service beneficiaries between 15 and 45 years of age having at least one paid claim for folic acid during a one-year time period (between October 1, 2013, and September 30, 2014). While there are limitations to these data, such as the lack of information about dietary folic acid intake or over-the-counter folic acid use without a claim being paid through Medi-Cal, increased promotion for folic acid use in this population may be beneficial.

This year, Folic Acid Awareness Week is January 4th – 10th, 2015. To help providers promote the use of folic acid, the National Birth Defects Prevention Network has updated promotional and patient educational materials on their website, which are available in both English and Spanish: www.nbdpn.org/faaw2015.php.

References

  1. Berry RJ, Li Z, Erickson JD, et al. Prevention of neural tube defects with folic acid in China. China-U.S. collaborative project for neural tube defect prevention. N Engl J Med. 1999;341:1485 – 90.
  2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478 – 485.
  3. CDC. Trends in folic acid supplement intake among women of reproductive age – California, 2002 – 2006. MMWR 2007;56:1106 – 9. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5642a3.htm. Accessed: December 11, 2014.
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16. Policy Clarification for Naltrexone Long-Acting Injection (Vivitrol)

Naltrexone long-acting injection (Vivitrol) is a covered benefit of the Medi-Cal program and is available to all Medi-Cal beneficiaries who demonstrate a medical necessity for the use of the drug. It may be billed as either a medical claim (for all Medi-Cal beneficiaries) or a pharmacy claim (for select populations only, as indicated below).

Medical Claims

The policy for naltrexone long-acting injection, when provided as a medical benefit, can be found in the Injections: Drugs N – R section of the Medi-Cal Part 2 provider manual.

Pharmacy Claims

Naltrexone long-acting injection is available as a pharmacy benefit to Medi-Cal beneficiaries meeting both of the following criteria:

  1. Charged with, or convicted of, a felony or misdemeanor; and
  2. Monitored for compliance with terms and conditions of county or state supervision (including but not limited to probation, parole, 1210 PC, mandatory supervision, post-release community supervision or pretrial release), including substance abuse monitoring.

Naltrexone long-acting injection always requires a Treatment Authorization Request (TAR) and may be obtained and billed only through the specialty pharmacy network.

Medi-Cal also covers the following medications for the treatment of alcohol and opioid dependence and/or prevention of relapse: acamprosate, buprenorphine, buprenorphine/naloxone, disulfiram and oral naltrexone (a TAR is required for all but disulfiram and oral naltrexone). Opioid agonist treatment with methadone is available within an opioid treatment program.

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17. Policy Clarification for Omeprazole Magnesium Products

The Department of Health Care Services would like to remind providers to submit National Drug Codes (NDCs) rather than Universal Product Codes (UPCs) when billing for omeprazole magnesium products. For dates of service on or after March 1, 2015 pharmacy claims for omeprazole magnesium products will no longer be reimbursed when billed using the UPCs. These claims will reject, even with a valid Treatment Authorization Request (TAR) or Service Authorization Request (SAR).

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18. Corrections: Blood Glucose Monitor Codes

HCPCS codes E2100 (blood glucose monitor with integrated voice synthesizer) and E2101 (blood glucose monitor with integrated lancing/blood sample) are not billed "By Report" as previously stated in the provider manual.

Reimbursement for HCPCS codes E0607 (home blood glucose monitor), E2100 and E2101 is limited to one glucometer every five years. The provider manual had previously and incorrectly stated the reimbursement rate was one per year.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
prescript (8); preg early (4)
Obstetrics preg early (4)
Durable Medical Equipment
Pharmacy
dura bil dme (20)
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19. Reminder: Rendering Provider Numbers Required for Group Providers

In compliance with federal regulation (42 CFR 455.410), all ordering and referring physicians or other professionals providing services under the State Plan, or under a waiver of the State Plan, must be enrolled as Medi-Cal providers.

Effective for dates of service on or after February 1, 2015, all services billed by physician group providers will require a valid enrolled Medi-Cal rendering provider number on the claim for pathology services, radiology services, maternity care services and out-of-state providers as previous exemptions for these services will be discontinued.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
General Medicine
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Therapies
cms comp (21)
Vision Care cms comp vc (11)
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20. Reminder: Medi-Cal Payment Considered 'Payment in Full'

The Department of Health Care Services (DHCS) reminds all providers that Medi-Cal payment is considered “payment in full” for covered services, according to Title 42 of the Code of Federal Regulations, Section 447.15, and California law in Welfare and Institutions Code (W&I Code) Section 14019.3. Providers may not charge any costs, other than nominal copays and share of cost if applicable, for any service in the Medi-Cal scope of benefits to recipients who identify themselves as having Medi-Cal coverage.

Medi-Cal’s payment rates include costs for providing the service, including writing prescription refills, telephone calls with patients, and emails with patients. Providers may not bill a recipient an annual or per-item fee for these ancillary services for covered benefits.

When providers sign the Medi-Cal Provider Agreement, they agree that payment from the Medi-Cal program constitutes payment in full for covered services. In addition, the provider agrees not to submit claims or otherwise collect reimbursement from a Medi-Cal recipient for any service included in the Medi-Cal scope of benefits in addition to a claim submitted to the Medi-Cal program for the service. Nominal copayments are an exception to this rule, since W&I Code Section 14134 authorizes copayments for Medi-Cal services.

When recipients apply for Medi-Cal, DHCS informs them that providers cannot collect insurance co-payment, coinsurance, or deductibles from them unless the payment is used to meet their Medi-Cal share of cost if applicable and/or nominal co-payment.

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21. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails for urgent announcements and other updates shortly, after posting on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form
  2. Enter your email address and ZIP code
  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

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