Medi-Cal Update

Inpatient Services | January 2013 | Bulletin 460

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1. Medical Exemption Requests Processed Incorrectly

Medical Exemption Requests (MERs) submitted to the Department of Health Care Services (DHCS) between March 2011 and the middle of October 2012 were not processed correctly. Two processing errors occurred: 1) Beneficiaries were not consistently mailed an MER denial notice, and/or 2) MERs were denied immediately rather than being placed in an incomplete status for 30 days while additional medical documentation was requested from the submitting doctor.

Beneficiaries impacted by these errors will be mailed a letter during the first half of January 2013 giving them the option to submit a new MER or to request a State Fair Hearing (depending on which error group they fall into). These beneficiaries may submit a new MER or request a State Fair Hearing while remaining in their currently assigned Medi-Cal Managed Care Plan, or they may elect to return to fee-for-service Medi-Cal. Current Medi-Cal Managed Care Plan beneficiaries who were previously treated by fee-for-service providers may request to move back to fee-for-service Medi-Cal, and they may contact providers to assist them in submitting a new MER.

For additional information about the MER process, please review the Request for Medical Exemption From Plan Enrollment form.

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2. New Medi-Cal Ordering/Referring/Prescribing Provider Application Available

The new Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement For Physician and Non-physician Practitioners (DHCS 6219) application form has been added to the Application Forms section of the Provider Enrollment web page of the Medi-Cal website.

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3. Medi-Cal Officially Goes Live with the Medi-Cal Subscription Service

The Department of Health Care Services (DHCS), in conjunction with its Fiscal Intermediary (FI), Xerox State Healthcare, LLC (Xerox), is pleased to announce that the new Medi-Cal Subscription Service (MCSS) went live on December 20, 2012.

The MCSS Subscriber Form and MCSS home page were first made available to the public in November and the number of subscribers has continued to grow each day. Medi-Cal delivered an email notification of its first "Go Live" Medi-Cal NewsFlash article, "Enhancements Added to the Medi-Cal Website," to more than 500 MCSS subscribers. The NewsFlash article described several enhancements to the Medi-Cal's home page in conjunction with the implementation of MCSS.

MCSS is scheduled to start delivery of Medi-Cal Update bulletin notifications to subscribers in January 2013.

Subscribe Today
Medi-Cal invites and encourages interested parties to subscribe to MCSS, free of charge, simply by locating the MCSS Subscriber Form on the Medi-Cal website and completing the following steps:

If you have previously submitted an MCSS Subscriber Form and did not receive an email notification of the Medi-Cal NewsFlash article, "Enhancements Added to the Medi-Cal Website," please check your inbox or junk mail folders for the MCSS confirmation email and click on the link as described above. Should subscribers not find the subscription confirmation email in their inbox or junk mail folder after 48 hours, then it is strongly recommended that they subscribe to MCSS using an alternate email address.

Please visit the MCSS Help page for more information about MCSS.

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4. Correction to ICD-9-CM Code Restrictions

Effective retroactively for dates of service on or after October 1, 2007, ICD-9-CM codes 258.01–258.03 (Multiple endocrine neoplasia [MEN] type I, IIA and IIB), V18.11 Family history of: (Multiple endocrine neoplasia [MEN] syndrome) and V84.81 (Genetic susceptibility to multiple endocrine neoplasia [MEN]) may be used to bill for both men and women. The description for each of these codes includes the acronym MEN, which may have caused some confusion when these codes became effective.

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims that were inappropriately denied for services provided to females. Providers do not need to resubmit these denials.

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5. Diagnosis-Related Groups: Executive Summary and Requested 2009 Data

Effective for admissions on or after July 1, 2013, reimbursement for private inpatient general acute care hospitals will be based on a Diagnosis-Related Group (DRG) payment methodology.

Executive Summary
The Department of Health Care Services (DHCS) requests that providers read the DRG Executive Summary. The summary contains the following important information about the upcoming DRG payment methodology being instituted by Medi-Cal:

The Department also requests that providers read Hospital Billing and Operations Changes, which provides an overview of key changes in billing practices and treatment authorization.

2009 Data Requested
DHCS continues to accept requests for hospital-specific data that shows how claims from calendar year 2009 would have paid under the DRG methodology. Because this data includes confidential information, points of contact (POC) must sign a Data Use Agreement with DHCS to receive the data.

Hospitals that had identified an individual as a POC, but the POC has changed, should submit a new Data Use Agreement. Hospitals that have not identified a POC must establish one to facilitate communication about confidential DRG base prices and other non-confidential matters.

Communication may be initiated with DHCS via the DRG mailbox at The information should include the hospital’s name, National Provider Identifier (NPI) and the contact’s name, email address and telephone number. DHCS will use this contact information for future direct contact.

In addition to the DRG Executive Summary and Hospital Billing and Operations Changes, the following documents can be found on the Diagnosis Related Group Hospital Inpatient Payment Methodology Web page on the DHCS website under Important Information:

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6. Enteral Nutrition Products Requiring Separate Authorization

Effective retroactively for dates of service on or after September 1, 2009, Enteral Nutrition Flavoring Products (Contracted) are not included in a physician Service Code Grouping (SCG) and require a separate Service Authorization Request (SAR). Effective retroactively for dates of service on or after September 1, 2011, Enteral Amino Acid Products (Contracted) are not included in a physician SCG and require a separate SAR.

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 Education Agency
Medical Transportation
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
cal child sar (7); genetic (8)
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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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