Medi-Cal Update

Inpatient Services | February 2012 | Bulletin 449

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1. March 2012 Medi-Cal Provider Seminar

Throughout the year, the Department of Health Care Services (DHCS) and the new Fiscal Intermediary for Medi-Cal, Affiliated Computer Services (ACS), will conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, will cover the following topics:

The next seminar is scheduled for March 13, 2012, through March 14, 2012, at the Almansor Court Conference Center in Alhambra, California. Providers can access a class schedule and RSVP for the seminars by visiting the Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar dates that they would like to attend.

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

Providers may also schedule a custom billing workshop by contacting their Regional Representative in one of the following ways:

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2. National Correct Coding Initiative Quarterly Update for January 2012

The Centers for Medicare & Medicaid Services (CMS) released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits will be incorporated into the Medi-Cal claims processing system and applied to claims effective for dates of service on or after January 1, 2012. For additional information, refer to the CMS NCCI website.

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3. Low Income Health Programs: Out-of-Network Emergency Services

Payment for out-of-network emergency and specified post-stabilization services are available through the Low Income Health Programs (LIHPs) for services rendered to certain program enrollees. Payment conditions and rates for out-of-network emergency and post-stabilization services are outlined as follows.

Background
As the Department of Health Care Services (DHCS) announced on January 5, 2011, local governmental entities have an opportunity to implement a LIHP to expand health care coverage to certain low-income adults who are between the ages of 19 and 64 with family incomes at or below 200 percent of the Federal Poverty Level (FPL). This program is authorized pursuant to Assembly Bill 342 (Chapter 723, Statutes of 2010) and AB 1066 (Chapter 86, Statutes of 2011) as delineated in the California Welfare and Institutions Code, Sections 15909-15916, and approved by the Centers for Medicare & Medicaid Services (CMS) under California’s section 1115(a) “Bridge to Reform” Medicaid Demonstration. The Special Terms and Conditions (STCs) provide details regarding DHCS operation of this Demonstration. The following ten counties implemented local LIHPs as of July 1, 2011: Alameda, Contra Costa, Kern, Los Angeles, Orange, San Diego, San Francisco, San Mateo, Santa Clara and Ventura. Local LIHPs for the remaining approved applicants will roll out on a flow basis as contracts are executed and programs are implemented. The programs will be effective through December 31, 2013, when the majority of enrollees become Medi-Cal eligible under national health care reform.

Each local LIHP will set its own income eligibility standard and may operate a Medicaid Coverage Expansion (MCE) Program for individuals with incomes at or below 133 percent of the FPL and an optional Health Care Coverage Initiative (HCCI) Program for individuals with incomes above 133 and up to 200 percent of the FPL. These local LIHPs will provide a limited scope of services, generally through closed provider networks.

LIHPs are not required to pay for emergency and specified post-stabilization services that are provided outside their network delivery system. Under limited circumstances, however, LIHPs will be required to pay for medically necessary emergency care services (including emergency transportation) and required post-stabilization care for MCE enrollees. The LIHP may deny payment for any out-of-network emergency and specified post-stabilization services that are not described in this bulletin. LIHPs are not required to pay for the out-of-network emergency and post-stabilization services described in this bulletin that are furnished to HCCI enrollees (STCs 63.e and f)

Scope of Covered Out-of-Network Emergency and Post-Stabilization Services
Local LIHPs must provide coverage for emergency services (including psychiatric emergency services that meet the definition of an emergency medical condition) provided in the United States in a hospital emergency room for emergency medical conditions and required post-stabilization care for MCE enrollees, whether the provider that renders the care is inside or outside of the LIHP network. If the emergency provider is not a LIHP network provider, the LIHP is required to pay for services rendered to an enrollee only if the enrollee falls within the MCE population and only if the requirements of this bulletin have been met.

Payment for Out-of-Network Emergency and Required Post-stabilization Services for MCE Enrollees
The local LIHP’s financial liability in instances of emergency and post-stabilization services provided by out-of-network providers is limited to MCE enrollees. Payment to providers is contingent on the satisfaction of two conditions: notifying the local LIHP of the patient’s emergency room visit and adhering to local LIHP protocols for approval of post-stabilization services.

Payment Rates and Balance Billing
Out-of-network providers must accept LIHP rates as payment in full for services rendered to MCE enrollees and may not balance bill MCE enrollees or otherwise hold MCE enrollees liable for payment. If the local LIHP denies payment for emergency services or post-stabilization care based on the provider’s failure to notify the local LIHP or comply with the local LIHP’s protocol, the provider may not bill the MCE enrollee for the services.

Local LIHPs may pay the following amounts for medically necessary out-of-network emergency and post stabilization services, including services provided out of state, but only as required by the Code of Federal Regulations, Title 42, Section 431.52(b)(1):

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4. Reimbursement for Computed Tomography Angiography (CTA)

Computed tomography angiography (CTA) is a computed tomography technique that provides high resolution vascular images and detailed images of the adjacent bone and soft tissue. It is non-invasive, with injection of the contrast medium through a peripheral vein. As a reminder, effective retroactive to October 1, 2011, providers may be reimbursed for the following CPT-4 codes:

CPT-4 Code Description
70496 CTA, head, with contrast material(s), including non-contrast images, if performed and image postprocessing
70498 CTA, neck, with contrast material(s), including non-contrast images, if performed and image postprocessing
71275 CTA, chest, [noncoronary] with contrast material[s], including non-contrast images, if performed, and image postprocessing
72191 CTA, pelvis, with contrast material(s), including non-contrast images, if performed and image postprocessing
73206 CTA, upper extremity, with contrast material(s), including non-contrast images, if performed and image postprocessing
73706 CTA, lower extremity, with contrast material(s), including non-contrast images, if performed and image postprocessing
74175 CTA, abdomen, with contrast material(s), including non-contrast images, if performed and image postprocessing

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Inpatient Services
tar and noncd7 (1–2)
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5. HIPAA ASC X12N 5010, NCPDP D.0 & 1.2 Transactions Update: Crossover Claims

Medi-Cal receives electronic 837 Institutional (I) and 837 Professional (P) automatic crossover claim files from the Medicare Coordination of Benefits Contractor (COBC) Group Health Incorporated (GHI). Medi-Cal will process automatic crossover claims in the 5010 format whether the claim was submitted to Medicare in the 4010A1 or 5010 format. COBC NCPDP crossover claim files will not be processed in the new format at this time, due to the lack of COBC NCPDP crossover claims for California.

Please note the following:

Direct Billed Crossover Claims
If a crossover claim does not automatically cross over electronically, providers can directly bill Medi-Cal either electronically through CMC with the 837I, 837P and NCPDP transactions or on paper.

CMS Announcement of Discretion Period
The compliance date for the implementation of Version 5010 and National Council for Prescription Drug Programs (NCPDP) D.0 and 1.2 transactions remains January 1, 2012; however, the Centers for Medicare & Medicaid Services’ (CMS), Office of E-Health Standards and Services (OESS) announced an Enforcement Discretion period of 90 days. Information about the CMS announcement is available at the CMS website in a November 17, 2011, news article titled Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services Announces 90-Day Period of Enforcement Discretion for Compliance with New HIPAA Transaction Standards.

Resources
Information about Medicare’s conversion to 5010 can be found on the CMS website. Details about Medicare’s EDI Help Line numbers, by jurisdiction, can be found on the Overview page of the CMS website.

Questions related to automatic crossover claims submitted to Medicare should be directed to Part A and Part B Medicare Administrative Contractor for California, Palmetto GBA. More information about Palmetto GBA implementation of 5010 can be found on the 5010 page of Palmetto’s website.

Providers should continue to access the Medi-Cal website and Medi-Cal Updates provider bulletins for information about the 5010 and NCPDP D.0/1.2 implementation. Providers may also call the Telephone Service Center (TSC) at 1-800-541-5555 and choose the appropriate option for language (English or Spanish), option 1 for provider, option 4 for the Technical Help Desk, option 2 for CMC/HIPAA, option 1 for provider or option 2 for submitter and follow the prompts to enter your provider ID, NPI, or submitter ID, followed by option 4 for HIPAA.
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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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