Medi-Cal Update

General Medicine | February 2017 | Bulletin 512

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

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2. Update: DHCS Fiscal Intermediary Name Change

Effective immediately, providers may notice that the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) for the Medi-Cal program, formerly Xerox State Healthcare, LLC (Xerox), is operating under a new company name, “Conduent.” Providers may also see the Conduent logo on some items.

Operations and interactions with providers are not impacted by this FI name change.

Providers may see this name change in items such as:

  • NewsFlash articles and Medi-Cal Update bulletins
  • Medi-Cal website (www.medi-cal.ca.gov)
  • Forms and User Guides
  • Provider Manuals
  • Medi-Cal Learning Portal (MLP)
  • Presentations at Provider Training Seminars
  • Provider Letters, such as Erroneous Payment Corrections (EPCs)
  • Additional hard copy correspondence
  • Emails with an “@conduent.com” address rather than an “@xerox.com” address
  • References to the Conduent name when researching mailing addresses or published telephone numbers
Conduent logo

There are no changes in the telephone numbers used by providers, including the Telephone Service Center (TSC) number (1-800-541-5555), as a result of this name change. The mailing addresses used by providers to conduct business with DHCS and the FI will remain the same.

Medi-Cal providers are strongly encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles, and System Status Alerts. Providers may sign up for MCSS by visiting http://www.medi-cal.ca.gov and completing the MCSS Subscriber Form. For more information about Conduent, visit https://www.conduent.com.

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3. Pharmacy Billing for Aid-in-Dying Drugs

Pharmacists must submit aid-in-dying drug claims on the CMS-1500 claim form. Refer to the End of Life Option Act Services and End of Life Option Act Services Billing Examples: CMS-1500 sections of the appropriate Part 2 provider manual for specific billing information for pharmacy claims. The End of Life Option Act (ELOA) does not specify which drugs are permitted for use as aid-in-dying drugs; therefore, Medi-Cal will provide reimbursement for any drugs prescribed by the attending physician for this purpose. Claims submitted without compliance to provider manual instructions will be denied. Claims submitted via the Point of Service (POS) system will also be denied.

Because participation in ELOA services is voluntary, pharmacy providers are not required to dispense aid-in-dying drugs. However, it is unlawful for a pharmacy provider to require a Medi-Cal recipient to pay for aid-in-dying drugs, or to withhold dispensing of aid-in-dying drugs until the provider receives payment from the Department of Health Care Services (DHCS). Medi-Cal enrolled providers must comply with the Medi-Cal billing requirements specified in Welfare and Institutions Code (W&I Code), Sections 14019.4 and 14115 and California Code of Regulations (CCR), Title 22, Section 51002. Medi-Cal providers are prohibited from billing recipients for covered services, except under specific authorized instances pursuant to CCR, Title 22, Section 51002.

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4. Medi-Cal List of Contract Drugs

The following provider manual sections have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or 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.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2017 OLARATUMAB Drug added, administration added, restriction added drugs cdl p1c (12)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2017 NECITUMUMAB Restriction added drugs cdl p1c (3)
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5. Authorized Drug Manufacturer Labeler Codes Update

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

Terminations, effective January 1, 2017
NDC Labeler Code Contracting Company's Name
69618 RELIABLE 1 LABORATORIES, 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 (18)
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6. Influenza Vaccine Extended to Presumptive Eligibility for Pregnant Women

Effective retroactively for dates of service on or after August 1, 2016, CPT-4 code 90674 (influenza virus vaccine, quadrivalent [ccIIV4], derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use) is a benefit extended to the Presumptive Eligibility for Pregnant Women program.

Administered under the brand name Flucelvax, code 90674 has been approved as a routine, annual influenza vaccination.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (15)
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7. Automation of PE for Pregnant Women Program

Effective April 1, 2017, the automation of the Presumptive Eligibility for Pregnant Women (PE4PW) program will be available on the “Transactions Services” tab of the Medi-Cal Web page. Providers who elect to participate in the PE4PW program and meet the eligibility requirements as governed by the Department of Health Care Services (DHCS) can enroll pregnant women for temporary prenatal and ambulatory benefits with no Share of Cost (SOC) through an online process.

The automation of this program will streamline the current paper process as it reduces paper waste, provides a real-time eligibility response and produces a temporary, immediate-need card for participating providers to print. Providers will no longer need to request enrollment packets from DHCS as the MC 263 forms will be available online to download, print, complete and enter into the online enrollment application.

Some requirements are changing. New and existing participating providers must:

To avoid service disruption, existing Qualified Providers (QPs) of the PE4PW Program will have a six-month soft cutover to transition into the PE4PW automation. QPs will be grandfathered into the automation process, which grants access to the recipient online enrollment application. To retain online access, QPs have a six-month grace period from the implementation date to resubmit the new MC 311 form. During the six-month transition, QPs can submit enrollment applications using either the manual or online process.

For more details about PE4PW automation, providers may refer to the Presumptive Eligibility for Pregnant Women Frequently Asked Questions page of the DHCS website.

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8. PE Program Adds Treponema Pallidum Antibody Benefit

Effective for dates of service on or after March 1, 2017, CPT-4 code 86780 (antibody; treponema pallidum) is reimbursable under the Presumptive Eligibility (PE) program.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (11)
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9. Presumptive Eligibility Provider Manual Section Revised

Information and forms in the Presumptive Eligibility section have been outdated for some time. The section has been updated to reflect current practices.

The section is now called Presumptive Eligibility for Pregnant Women. A new abbreviation has been introduced in the section, PE4PW. The new abbreviation is coming into use with the automation of the process that allows pregnant women to become presumptively eligible for Medi-Cal until it is determined if they qualify for Medi-Cal.

Providers should anticipate the Presumptive Eligibility for Pregnant Women section to be updated again soon. New PE4PW automation information will be added as appropriate. The section will retain existing information for adjudicating older claims and appeals until the Department of Health Care Services directs its removal.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg early (1); presum (1–20)
Pharmacy presum (1–20)
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10. Billing and Frequency Clarified for Central Nervous System Assessments/Tests

Effective retroactively for dates of service on or after July 1, 2014, CPT-4 code 96118 (neuropsychological testing, per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report) is reimbursable once-in-a-lifetime for one episode of testing (eight hours), unless otherwise approved with a Treatment Authorization Request (TAR) that justifies medical necessity.

A California Children’s Services (CCS) or Genetically Handicapped Persons Program (GHPP) Service Authorization Request (SAR) will override any frequency restrictions for code 96118.

All hours must be billed on the last day of service. Claims must also include an attachment specifying the amount of time spent completing each of the following:

Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). No action is required of providers.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
medne neu (8); once (6); spec (3)
Psychological Services psychol (4, 6); spec (3)
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11. Policy Updates for Several Central Nervous System Assessments/Tests

Effective for dates of service on or after March 1, 2017, policy related to several central nervous system assessments/tests is updated as shown in the table below:

CPT-4 Code Description Policy Update
96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorshach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting test results and preparing the report Frequency limit is one test (≤8 hours) per year for any provider. A Treatment Authorization Request (TAR) override is allowed.

All hours must be billed on the last day of service.

Claims must include an attachment specifying the amount of time spent completing each of the following: administration of test(s), interpretation of test results and preparation of the report.

Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour Frequency limit is two episodes (≤3 hours each) per year for any provider. A TAR override is allowed.

All hours for each episode must be billed on the last day of service.

Claims must include an attachment specifying the amount of time spent completing each of the following: administration of test(s), interpretation of test results and preparation of the report.

Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.
96110 Developmental screening (eg., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument Frequency limit is two screenings per year for any provider. A TAR override is allowed.
Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.
96111 Developmental testing, (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report Frequency limit is one test per year for any provider. A TAR override is allowed.

Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report Frequency limit is one exam (≤4 hours) per year for any provider. A TAR override is allowed.

All hours must be billed on the last day of service.

Claims must include an attachment specifying the amount of time spent completing each of the following: administration of test(s), interpretation of test results and preparation of the report.

Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.
96120 Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Providers must list the tests performed either in the Additional Claim Information field (Box 19) or on an attachment.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
medne neu (8); spec (3)
Psychological Services psychol (4–6); psychol cd (2); spec (3)
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12. Terminated Dialysis HCPCS Local Codes

Effective for dates of service on or after March 1, 2017, the following HCPCS Level III-local codes used to reimburse dialysis maintenance and training services are terminated due to low or no utilization:

Code Description
Z6016 Maintenance dialysis including professional charges and routine laboratory services (CMS approved)
Z6018 Maintenance dialysis including professional charges (CMS approved)
Z6022 Maintenance dialysis only (CMS approved)
Z6036 Home training dialysis including professional charges and routine laboratory charges (CMS approved)
Z6038 Home training dialysis including professional charges (CMS approved)
Z6040 Home training dialysis including routine laboratory charges (CMS approved)

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
dial chr (2, 4, 5, 8); dial end (2)
General Medicine dial end (2)
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13. Modifier UA and UB Rates Spreadsheet Update

The rates spreadsheet for surgical and anesthesia-related supplies and drugs modifiers UA and UB has been updated. Providers may refer to the Medi-Cal Rates page of the Medi-Cal website to download a copy of the updated spreadsheet.

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14. Provider Orientation

Family PACT

The Family Planning, Access, Care and Treatment (Family PACT) Program will offer a Provider Orientation in February (Oakland).

Medi-Cal providers applying to become a Family PACT provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Family PACT Provider Orientation provides an overview of the Family PACT Program, provider enrollment process, program standards and benefits and client eligibility and enrollment. A Certificate of Attendance is issued at the end of the session.

Solo or group providers, or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility.

Provider Orientation Highlights

Upcoming Provider Orientation

Oakland
February 28, 2017
9:00 a.m. – 4:00 p.m.
Elihu Harris Building, Room #2
1515 Clay Street
Oakland, CA 94612

For more information about Provider Orientations, call (916) 650-0414.

Registration

The registration form should be submitted in an electronic format.

To register for a Provider Orientation:

Providers experiencing problems using the “Submit by email” button should fax the registration form to (916) 440-5634 or send as an attachment to ProviderServices@dhcs.ca.gov.

Check-In
Check-in begins at 8:30 a.m. and ends at 8:50 a.m. Those attending to certify a site must check-in no later than 8:50 a.m. and attend the entire orientation to receive a Certificate of Attendance. A late check-in will not be accepted and no exceptions will be made, as Family PACT policy requires the site certifier to attend the entire orientation. Site certifiers must present a State-issued photo identification upon check-in.

Field representatives from Conduent, the Department of Health Care Services’ (DHCS) Fiscal Intermediary (FI), will be available for questions about billing and claims.

Note:

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

Upon completion of the Provider Orientation, site certifiers will receive a copy of the signed Certificate of Attendance. The original certificate is retained by DHCS. A Certificate of Attendance is not transferable. A separate certificate is prepared for each provider site.

Although non-certifying provider staff members are encouraged to attend Provider Orientation sessions to stay current with program policies, procedures and services, they are not eligible to receive a Certificate of Attendance or certify a service site for enrollment. The provider staff members receive a Proof of Participation.

Contact Information
For more information about the Family PACT Program, call 1-800-942-1054 or visit the Family PACT website.

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15. March 2017 Medi-Cal Provider Seminar

The next Medi-Cal Provider Seminar is scheduled for March 14, 2017, at the Red Lion Hotel Redding, California. Providers can access a class schedule for the seminar by visiting the Provider Training Web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date 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 Fiscal Intermediary for Medi-Cal, Conduent, 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 February 28, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After February 28, 2017, 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 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 representative.

Providers are encouraged to bookmark the Provider Training Web page and refer to it often for current seminar information.

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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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