Medi-Cal Update

General Medicine | March 2018 | Bulletin 525

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1. It's Live: Online PDF RAD and Medi-Cal Financial Summary

Providers can now securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs are available on the Medi-Cal website under the Transactions tab.

Note:

To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

PDF RAD User Guide
The PDF RAD Web Portal User Guide is now available on the Medi-Cal website. The user guide contains step-by-step instructions to help providers view and download the PDF version of their RAD. Providers may download the guide from the User Guides page of the Medi-Cal website.

Benefits of PDF RAD
There are many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments are made via PDF RADS. They are informational only.

Providers may refer to future Medi-Cal Update bulletins for PDF RAD updates.

835 Transactions
Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246). The form is located on the Forms page of the Medi-Cal website. The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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2. Provider Manuals Updated to Reflect New Medicare Beneficiary Identifier Standards

On April 1, 2018, the Centers for Medicare & Medicaid Services (CMS) will start mailing Medicare cards with new Medicare Beneficiary Identifiers (MBIs) to everyone with Medicare. The MBI will replace the Social Security Number (SSN)-based Health Insurance Claim (HIC) number for transactions like billing, eligibility status and claim status after a transition period.

The Medi-Cal provider manuals have been updated to change references of HIC to “Medicare ID” in most instances. Also, the HIC field on the Automated Eligibility Verification System (AEVS) Response Log has been revised to “Medicare ID.”

Providers must be ready to accept the new MBIs beginning April 1, 2018. People new to Medicare after April 1 will only receive a card with the MBI. For more specifics, providers may refer to the December 2017 article SSN Removal Initiative to Replace HIC Number on Medicare Cards on the Medi-Cal website.

Additional information is available by calling the Telephone Service Center at 1-800-541-5555, option 5, followed by option 6. Recipients may call the same number and access option 2. Also watch for announcements about this transition in future Medi-Cal Updates.

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

Provider Manual(s) Page(s) Updated
Part 1 aev trn 1 form (1); medicare (1, 6, 11, 12)
Adult Day Health Care Centers
Expanded Access to Primary Care Program
Local Educational Agency
Multipurpose Senior Services Program
ub comp op (22)
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Rehabilitation Clinics
medi cr op (3, 11, 29); medi cr op ex (2, 3, 5, 8, 11, 12, 15, 16); ub comp op (22)
Audiology and Hearing Aids
General Medicine
Obstetrics
medi cr cms (4, 20)
Chiropractic
Durable Medical Equipment
Medical Transportation
Orthotics and Prosthetics
Psychological Services
Therapies
medi cr cms (4, 20); medi cr ub (1, 2); medi cr ub ex (3, 5, 8, 9)
Inpatient Services medi cr ip (8, 10, 14, 15, 17); medi cr ip ex (4, 7, 10, 14, 17); ub comp ip (21)
Long Term Care medi cr ltc (5, 7, 10, 11); medi cr ltc ex (4, 7)
Pharmacy medi cr ph (3, 4, 8, 22, 23); medi cr ph ex (2–5, 7–9, 11, 13, 15, 17)
Vision Care medi cr vc (3, 4)
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3. Daily Management of Epidural Opioid Administration Policy Update

Effective retroactively for dates of service on or after March 1, 2009, billing code Z0310 is no longer reimbursable.

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
modif used (11)
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4. Update to EWC Diagnostic and Screening Mammography Benefits

A previously published Medi-Cal Update that added, changed and deleted CPT-4 and HCPCS codes for the 2018 annual update, effective February 1, 2018, failed to establish that the following HCPCS codes are no longer benefits for the Every Woman Counts (EWC) program:

HCPCS Code Description
G0202 Screening mammography, bilateral, including CAD when performed
G0204 Diagnostic mammography, including CAD when performed; bilateral
G0206 Diagnostic mammography, including CAD when performed; unilateral

Instead, providers should use the following CPT-4 codes when billing for screening or diagnostic mammography:

CPT-4 Code Description
77065 Diagnostic mammography, including CAD when performed; unilateral
77066 Diagnostic mammography, including CAD when performed; bilateral
77067 Screening mammography, bilateral, including CAD when performed

For specific billing policy for CPT-4 codes 77065 – 77067, providers should refer to the November 20, 2017, NewsFlash article titled “Update to EWC Diagnostic and Screening Mammography Benefits”, and Every Woman Counts in the appropriate Part 2 manual.

Providers should refer to the HCPCS Annual Update web page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (8, 24, 34, 36)
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5. Every Woman Counts Income Eligibility Guidelines Update

Effective April 1, 2018, through March 31, 2019, Every Woman Counts (EWC) providers are to use the following income guidelines when determining recipient eligibility for EWC. Providers should disregard all previous EWC income eligibility guideline charts.

EWC recipients must have a household income at or below 200 percent of the federal Health and Human Services (HHS) poverty guidelines. The HHS poverty guidelines are adjusted annually. “Gross household income” means income before taxes and other deductions.

EWC Income Eligibility Guidelines
200 Percent of the 2018 HHS Poverty Guidelines by Household Size
Effective April 1, 2018, through March 31, 2019
Number of Persons Living in Household Monthly Gross Household Income Annual Gross Household Income
1 $2,023 $24,280
2 $2,743 $32,920
3 $3,463 $41,560
4 $4,183 $50,200
5 $4,903 $58,840
6 $5,623 $67,480
7 $6,343 $76,120
8 $7,063 $84,760
For each additional person, add: $720 $8,640

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (10)
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6. New Sequence Analysis for Molecular Pathology Procedures

Effective for dates of service on or after April 1, 2018, the TP53 test (tumor protein 53, targeted sequence analysis of 2–5 exons) is a Medi-Cal benefit reimbursable under both CPT-4 codes 81404 (molecular pathology procedure, level 5) and 81405 (molecular pathology procedure, level 6) with any of the following numbered Treatment Authorization Request (TAR) criteria:

  1. All of the following conditions:
    • The patient has sarcoma diagnosed before 45 years of age, and

    • A first-degree relative with any cancer before 45 years of age, and

    • A first or second-degree relative with any cancer before 45 years of age, or a sarcoma at any age; or
  2. All of the following conditions:
    • A tumor belonging to the Li-Fraumeni Syndrome (LFS) tumor spectrum (soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumor, adrenocortical carcinoma, leukemia or lung bronchoalveolar cancer) before 46 years of age, and

    • At least one first or second-degree relative with an LFS tumor (except breast cancer if the patient has breast cancer) before 56 years of age or with multiple tumors; or
  3. The patient has multiple tumors (except multiple breast tumors), two of which belong to the LFS tumor spectrum, and the first occurred before 46 years of age; or

  4. The patient is diagnosed with adrenocortical carcinoma or choroid plexus tumor.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (31, 35)
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7. New Molecular Pathology Benefit: Testing Retinal Pigment Protein 65kDa

Effective for dates of service on or after April 1, 2018, full gene sequence test RPE65 (retinal pigment epithelium-specific protein 65kDa) is a new Medi-Cal benefit under CPT-4 code 81406 (molecular pathology procedure, Level 7).

Reimbursement for this service requires an approved Treatment Authorization Request and requires providers to document the following:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (38)
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8. Medical Justification Needed for Limit Override for Nerve Pedicle Transfer

Effective for dates of service on or after April 1, 2018, the billing quantity limitation of one per date of service for CPT-4 code 64905 (nerve pedicle transfer; first stage) requires medical justification to allow override for quantities from two up to a maximum of six per day. This justification can be documented in the Remarks field (Box 80) on the UB-04 claim form, Additional Claim Information field (Box 19) on the CMS-1500 claim form or on an attachment. No documentation is necessary when billing for a quantity of one per date of service.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
surg nerv (16)
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9. Additional In Situ Hybridization Surgical Pathology Benefit

Effective for dates of service on or after April 1, 2018, CPT-4 code 88365 (in situ hybridization [eg, FISH], per specimen; initial single probe stain procedure) is a new Medi-Cal benefit. The code is split-billable and allows the following modifiers: 26, TC and 90. CPT-4 code 88365 has no age, gender or frequency restrictions and does not require a Treatment Authorization Request (TAR).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path surg (2); tar and non cd8 (4)
Inpatient Services tar and non cd8 (4)
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10. QASP Data Completeness Requirement Established

Effective September 1, 2017, a new data completeness requirement is established for the Quality and Accountability Supplemental Payment (QASP) Program for Freestanding Skilled Nursing Facilities. To be eligible for a QASP payment, each facility must submit complete resident assessment data no later than September 1 of each state fiscal year. Resident assessment data shall be considered complete if it is not missing 20 percent or more of expected resident assessments for performance year 2016 – 2017, 15 percent or more for performance year 2017 – 2018 and 10 percent or more for performance year 2018 – 2019 and subsequent performance years. The Minimum Data Set (MDS) submitted by facilities is the basis for QASP clinical quality measures and data completeness is required for valid measurement. Facilities with rates of missing assessments that exceed the standard for the applicable performance year are not eligible to receive a QASP payment for the associated payment year.

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11. Results of Payment Error Rate Measurement Review for Fiscal Year 2016

The California Department of Health Care Services (DHCS) wishes to notify all California Medi-Cal providers of the results of the federal fiscal year 2016 Payment Error Rate Measurement (PERM) review recently completed in California by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to identify erroneous payments made in the Medicaid program and the Children’s Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress, as required by the Improper Payments Information Act (IPIA).

During the fiscal year 2016 PERM, a total of 883 Medicaid and 572 CHIP Medi-Cal claims were selected for review from each quarter between October 1, 2015, and September 30, 2016. One type of error finding that comprised the majority of errors was providers failing to respond to requests for medical records. The other error finding cited most frequently was submission of insufficient documentation.

To reduce error findings in future PERM reviews and ensure that providers are in compliance with state and federal regulations, DHCS would like to remind providers of the following:

Not only do error findings affect California’s payment measurement rate, but claims cited with error findings at the conclusion of the review are also considered improperly paid. Therefore, in accordance with W&I Code Section 14172.5, DHCS is authorized to recoup these payments. Providers that receive a demand for recovery of claim payments are urged to remit the demand amount as soon as possible.

Provider cooperation will help ensure that the payment measurement rate for future PERM reviews is accurate and that California retains its much needed federal match monies for the Medi-Cal program.

Information about the upcoming fiscal year 2020 PERM review will soon be available on the Providers page of the CMS website as well as the Payment Error Rate Measurement Program page of the DHCS website. Providers can also email questions about PERM to DHCS at PERM@dhcs.ca.gov.

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12. Diabetes Prevention Program Established for Medi-Cal

Effective July 10, 2017, Senate Bill 97 (Chapter 52, Statutes of 2017), requires the Department of Health Care Services (DHCS) to establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems, consistent with the guidelines provided by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

A core benefit of Medi-Cal's DPP will include 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. Participants who achieve and maintain a minimum weight loss of 5 percent by the conclusion of the 12 month period will also be eligible to receive ongoing maintenance sessions to help them continue healthy lifestyle behaviors. SB 97 also requires that Medi-Cal providers choosing to offer DPP services comply with CDC guidance and obtain CDC recognition in connection with the National DPP.

The benefit will be available to eligible Medi-Cal recipients on January 1, 2019. DHCS is working with its Managed Care Plans, the Department of Public Health, Public Health Advocates and other interested stakeholders to discuss policy implications and potential collaborations. DHCS will begin drafting its policy and submit a CMS State Plan Amendment in 2018. To join the stakeholder list and to submit questions or comments, email DHCSDPP@dhcs.ca.gov.

DHCS is conducting a provider survey to better understand how Medi-Cal providers discuss prediabetes with their patients and to receive any comments or concerns regarding Medi-Cal's DPP benefit. DHCS would appreciate provider's feedback through a short 10-minute survey.

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13. Phase 2: RTD Generation to Be Discontinued

The Department of Health Care Services (DHCS) is phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1). The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. The first phase was implemented in November 2017 and the second phase was implemented in February 2018. The third phase is expected to implement in the second quarter of 2018. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. As DHCS transitions from the use of RTDs to claim denials, providers can expect to receive fewer RTDs. When the project is completed, the use of RTDs will be completely discontinued.

Providers are encouraged to routinely check the Medi-Cal website for more information.

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14. 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, 2018 ESLICARBAZEPINE ACETATE Drug added, administration added drugs cdl p1b (9)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
August 25, 2017 VANDETANIB Restriction added drugs cdl p1d (27)
October 1, 2017 THIOGUANINE Restriction added drugs cdl p1d (15)
December 1, 2017 BOSUTINIB Strength added drugs cdl p1a (24)
January 2, 2018 BRIGATINIB Restriction added, strength added drugs cdl p1a (24)
March 1, 2018 BUSULFAN Restrictions added drugs cdl p1a (28)
March 1, 2018 CHLORAMBUCIL Restrictions added drugs cdl p1a (35)
March 1, 2018 CINACALCET HCL Restriction added drugs cdl p1a (38)
March 1, 2018 FLUTICASONE PROPIONATE Restrictions added drugs cdl p1b (23)
March 1, 2018 FLUTICASONE PROPIONATE AND SALMETEROL Restriction changed drugs cdl p1b (23)
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15. Drug Safety Communication: New Age Limit for Opioid Cough and Cold Medicines

A new DUR Educational Article titled “Drug Safety Communication: New Age Limit for Opioid Cough and Cold Medicines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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16. April 2018 Medi-Cal Provider Seminar

The April Medi-Cal provider seminar is scheduled for April 18 – 19, 2018, at the California Center for the Arts in Escondido, 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(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 DHCS 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 April 4, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 4, 2018, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks 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 representative.

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

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

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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 shortly after urgent announcements and other updates post 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 and select a subscriber type
  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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18. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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