Medi-Cal Update

General Medicine | July 2018 | Bulletin 529

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1. Electronic SAR Now Supports Attachments

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can now submit Service Authorization Requests (SARs) in an electronic format (eSAR) with attachments. Attachments must be in format of PDF, JPG or TIF. Attachments must be less than 15 megabytes (MB) in size, with the sum of all attachments being less than 150 MB. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit eSARs, providers must:

Then, select one of the available options to submit:

Registered providers and clearinghouses can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or practical reasons to do so.

Providers interested in learning more about eSAR submissions should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (12); genetic (4)
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2. Supplemental Payments for Selected Providers Extended

Supplemental payments for selected providers will not expire in 2018 as previously announced but extend into 2019. The provider types for the supplemental payments are as follows: Physicians; Family Planning, Access, Care and Treatment (Family PACT); Abortion; and AIDS Waiver.

The supplemental payment date range is July 1, 2017 to June 30, 2019.

ICF/DD Correction and Payment Chart
The supplemental payment date range is August 1, 2017 to July 31, 2019 for the facility types listed below. This date range corrects the range announced in a NewsFlash article that posted in April 2018, titled Supplemental Payment Program Implemented for ICF-DD Services.

A single reimbursement payment includes the current per diem rate in addition to the supplemental payment amount shown below. The supplemental payment amount is automatically added to reimbursements for claims meeting the supplemental payment criteria.

ICF/DD Supplemental Payment Plan
Facility Type LTC Accommodation Code Bed Hold Accommodation Code Supplemental Payment Per Diem
ICF/DD 41 (1 – 59 beds) 43 $15.47
ICF/DD 41 (60+ beds) 43 $0.00
ICF/DD-H 61 (4 – 6 beds) 63 $10.75
ICF/DD-H 65 (7 – 15 beds) 68 $0.00
ICF/DD-N 62 (4 – 6 beds) 64 $12.47
ICF/DD-N 66 (7 – 15 beds) 69 $22.30

No action is required of providers. An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims.

Note:

Facilities in peer groups in which the unfrozen 2017 – 2018 65th percentile rate is lower than the current reimbursement rate will not receive the supplemental payment.

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3. Clinic Dispensing of Miscellaneous Drugs for Medi-Cal

Effective for dates of service on or after July 1, 2018, Medi-Cal providers may dispense a limited number of miscellaneous drugs for non-surgical procedures for the treatment of family planning-related conditions using Healthcare Common Procedure Coding System (HCPCS) code S5000 (prescription drug, generic) or S5001 (prescription drug, brand name). These codes may be used only by hospital outpatient departments, emergency rooms, surgical clinics and community clinics.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals fam planning (15–25); fam planning ub (8)
Family PACT drug onsite (3–5)
General Medicine
Obstetrics
fam planning (15–25)
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4. ELISA Technique for HIV-1 and HIV-2 Screening Added to CLIA-Waived List

Effective for dates of service on or after August 1, 2018, HCPCS code G0433 (infectious agent antibody detection by enzyme-linked immunosorbent assay [ELISA] technique, HIV-1 and/or HIV-2, screening) is reimbursable as a Clinical Laboratory Improvement Amendments (CLIA)-waived test. Modifier QW is allowable and can be used to indicate a CLIA-waived test kit was used, but is not required for reimbursement of HCPCS code G0433.

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
path bil (9)
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5. Updates to Molecular Pathology CPT-4 Codes

Effective for dates of service on or after August 1, 2018, HCPCS code 81310 (NPM1 [nucleophosmin] gene analysis, exon 12 variants) is a new Medi-Cal benefit. One of the following ICD-10-CM diagnosis codes is required on the claim: C92.00 – C92.02. Code 81310 has a frequency limit of once in a lifetime with TAR override. In addition, the following policy updates have been made to genetic testing for acute leukemia and human leukocyte antigen typing CPT-4 codes:

CPT-4 Code Description ICD-10-CM Diagnosis Codes Added
81120 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble), common variants C92.00 – C92.02
81121 IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial), common variants C92.00 – C92.02
81245 FLT3 (fms-related tyrosine kinase 3), gene analysis; internal tandem duplication (ITD) variants C92.00 – C92.02
81246 FLT3 (fms-related tyrosine kinase 3), gene analysis; tyrosine kinase domain (TKD) variants C92.00 – C92.02
81270 JAK2 (Janus kinase 2) gene analysis, p. Val617Phe (V617F) variant C91.00 – C91.02
81381 HLA Class I typing, high resolution; one allele or allele group, each Z01.812

CPT-4 Code Description New Treatment Authorization Request (TAR) Documentation Criteria
81405 Molecular pathology procedure, level 6 WT1 (Wilms tumor 1) – full gene sequence – The patient has suspected or confirmed acute myeloid leukemia, and the result of the test will influence the diagnosis, prognosis and/or therapeutic management
81407 Molecular pathology procedure, level 8 NOTCH1 (notch 1) – full gene sequence – The patient has suspected or confirmed acute lymphoblastic leukemia, and the result of the test will influence the diagnosis, prognosis and/or therapeutic management

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (2, 12, 15, 20, 47, 55, 57); tar and non cd8 (2)
Inpatient Services tar and non cd8 (2)
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6. Reminder: Voluntary Inpatient Detoxification is a Medi-Cal Benefit

In accordance with Senate Bill X1 1 (Hernandez, Chapter 4, Statutes of 2013), Section 29, and the Patient Protection and Affordable Care Act, voluntary inpatient detoxification is a Medi-Cal benefit for qualifying recipients, as medically necessary.

The detoxification services are fee-for-service benefits, reimbursed by diagnosis-related groups (DRG) methodology for inpatient general acute care hospitals that do not participate in certified public expenditure (CPE) reimbursement and reimbursed by CPE for designated public hospitals providing inpatient general acute care services.

Claims for voluntary inpatient detoxification should be submitted to the Medi-Cal Fiscal Intermediary (FI) as this service is not covered by Managed Care Plans (MCPs). The detoxification services must be identified on the claim in the Remarks field (Box 80) as “Voluntary Inpatient Detox,” or “Voluntary Inpatient Detoxification” or “VID.”

Facilitating TAR Approval
While not required for a medical necessity review of the Treatment Authorization Request (TAR), providers are encouraged to note “Voluntary Inpatient Detoxification” in the Medical Justification field of the paper TAR or “VID” in the special handling option of the eTAR. The documentation ensures the Department of Health Care Services (DHCS) is able to track service utilization.

For additional information, providers may refer to the following article:

Medi-Cal Benefits Expanded to Include Voluntary Inpatient Detoxification

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

Provider Manual(s) Page(s) Updated
Inpatient Services diagnosis ip (12)
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7. Coagulation Factor IX Rebinyn Added as a Medi-Cal Benefit

Effective retroactively for dates of service on or after January 1, 2018, Coagulation Factor IX, Rebinyn® is a Medi-Cal benefit and is reimbursable with HCPCS code J7199 (hemophilia clotting factor, not otherwise classified) and an approved Treatment Authorization Request (TAR).

Claims for code J7199 are billed “By Report” and must be accompanied with the National Drug Code (NDC), amount given, drug name and strength.

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8. New Skin Substitutes Added as Medi-Cal Benefits

Effective for dates of service on or after August 1, 2018, the following HCPCS codes are added as Medi-Cal benefits:

HCPCS Code Description
Q4159 Affinity, per sq cm
Q4160 Nushield, per sq cm

These codes must be billed “By Report.” A Treatment Authorization Request (TAR) is required.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
surg integ (4, 5)
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9. Reminder: VeriFone VX 520 POS Device to Decommission in July 2018

In July 2018, the VeriFone VX 520 Point of Service (POS) device will be decommissioned. Providers may contact the POS Help Desk at 1-800-541-5555 (option 5, followed by option 6) for information about the decommission and for options.

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10. Correction: No TAR Required for Copper IUDs

In a previous Medi-Cal Update published on May 31, 2018, the Department of Health Care Services (DHCS) introduced a new manual section titled Physician Administered Drugs in the Part 2 Medi-Cal Pharmacy provider manual. The new section stated in error that a Treatment Authorization Request (TAR) is always required for copper intrauterine devices (IUDs).

A TAR is not required for copper IUDs. This information has been corrected in the Physician Administered Drugs section.

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1)
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11. 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 July 1, 2018
NDC Labeler Code Contracting Company's Name
42385 LAURUS LABS LIMITED
59365 COOPERSURGICAL INC.
59917 ADARE PHARMACEUTICALS, INC.
69488 ADVANCED ACCELERATOR APPLICATIONS USA
69584 OXFORD PHARMACEUTICALS, LLC
70727 AERIE PHARMACEUTICALS, INC.
70954 NOVITIUM PHARMA LLC
71274 PHARMING HEALTHCARE INC.
71321 BRANDYWINE PHARMACEUTICALS, LLC
71332 RIGEL PHARMACEUTICALS, INC.
71709 METCURE PHARMACEUTICALS, INC.
71758 AVADEL SPECIALTY PHARMACEUTICALS LLC
71770 MEDUNIK USA

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 (8, 13, 18–20)
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12. Medi-Cal List of Contract Drugs

The following provider manual section(s) 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
August 17, 2017 INOTUZUMAB OZOGAMCIN Drug added, administration added, restriction added drugs cdl p1b (41)
April 1, 2018 COPANLISIB Drug added, administration added, restriction added drugs cdl p1a (47)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2017 GEMTUZUMAB OZOGAMICIN Restriction added, administration added drugs cdl p1b (28)
January 1, 2018 NIVOLUMAB Strength added drugs cdl p1c (7)
February 27, 2018 IBRUTINIB Strength added drugs cdl p1b (37)
March 21, 2018 IBRUTINIB Administration added drugs cdl p1b (37)
April 1, 2018 OLARATUMAB Strength added drugs cdl p1c (14)
July 1, 2018 ENOXAPARIN SODIUM Restriction removed drugs cdl p1b (5)
July 1, 2018 ESOMEPRAZOLE MAGNESIUM Restriction removed drugs cdl p1b (9)
July 1, 2018 MONTELUKAST SODIUM Restriction removed drugs cdl p1b (72)
July 1, 2018 NORETHINDRONE AND ETHINYL ESTRADIOL Restriction removed drugs cdl p1c (9)
July 1, 2018 PANTOPRAZOLE SODIUM Drug suspension removed, restriction removed, administration changed, strength added drugs cdl p1c (21)
August 1, 2018 DESOGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1a (54)
August 1, 2018 DROSPIRENONE/
ETHINYL ESTRADIOL/
LEVOMEFOLATE CALCIUM
Restriction changed drugs cdl p1a (65)
August 1, 2018 ESTRADIOL VALERATE/
DIENOGEST
Restriction changed drugs cdl p1b (11)
August 1, 2018 ETHYNODIOL DIACETATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1b (13)
August 1, 2018 ETONOGESTREL AND ETHINYL ESTRADIOL Restriction added drugs cdl p1b (14)
August 1, 2018 LEVONORGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1b (55)
August 1, 2018 NORELGESTROMIN AND ETHINYL ESTRADIOL Restriction added drugs cdl p1c (7)
August 1, 2018 NORETHINDRONE Restriction changed drugs cdl p1c (8)
August 1, 2018 NORETHINDRONE ACETATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (8)
August 1, 2018 NORETHINDRONE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (9)
August 1, 2018 NORETHINDRONE AND MESTRANOL Restriction changed drugs cdl p1c (10)
August 1, 2018 NORGESTIMATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (11)
August 1, 2018 NORGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (11)
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13. National Correct Coding Initiative Quarterly Update for July 2018

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are valid for dates of service on or after July 1, 2018.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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14. A New Way to Subscribe – Contact Medi-Cal Subscription Service Representatives

Medi-Cal is committed to keeping you up-to-date on the latest Medi-Cal news and policy updates.

The Medi-Cal Subscription Service (MCSS) is a free service that provides subscribers with personalized email notifications for urgent, high-impact announcements and monthly news/policy updates as they post to the Medi-Cal website.

Providers can now contact MCSS representatives directly at MCSSCalifornia@conduent.com to subscribe and for assistance with managing subscriptions. Subscribing is simple and free!

If you have not yet subscribed to MCSS, Medi-Cal encourages you to utilize one of the following two methods to subscribe.

To subscribe by email:
  1. Download the linked MCSS Subscriber Form

  2. Enter your name, email address, ZIP code and subscriber type in the appropriate fields

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Attach your completed form to an email and send to MCSSCalifornia@conduent.com
To subscribe online:
  1. Go to the MCSS Subscriber Form page on the Medi-Cal website

  2. Enter your email address and ZIP code, and select a subscriber type from the drop-down menu

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Click “Subscribe Now” at the bottom of the page

After the form has been received, 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, visit the MCSS Help page.

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15. Provider Orientation

Family PACT

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Provider Orientation training is delivered online and in person and includes information on comprehensive family planning, program benefits and services, client eligibility, provider responsibilities and compliance.

Each provider's service location is required to be certified for enrollment in the Family PACT Program. Applicants who are enrolled in Medi-Cal and in good standing or are pending Medi-Cal enrollment and who have submitted a Family PACT application packet may complete the Provider Orientation to certify a site for enrollment.

Each service location must designate one eligible representative to be the site certifier. The site certifier cannot certify multiple sites.

The medical director, physician, nurse practitioner or certified nurse midwife who is responsible for overseeing the family planning services rendered at the location to be enrolled is eligible to certify the site.

Provider Orientation details and registration information is posted on the Family PACT website at www.familypact.org.

Upcoming In-Person Orientation

Sacramento
August 22, 2018
10 a.m. – 2 p.m.
Sierra Health Foundation
1321 Garden Highway
Sacramento, CA  95833

Please contact the Office of Family Planning by phone (916) 650-0414 or email us at ProviderServices@dhcs.ca.gov if you have any questions regarding the orientation process.

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16. August 2018 Medi-Cal Provider Seminar

The August Medi-Cal provider seminar is scheduled for August 14 – 15, 2018, at the Sacramento Marriott in Sacramento, 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 July 31, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 31, 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

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 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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