Medi-Cal Update

Local Educational Agency | September 2018 | Bulletin 528

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1. April 2018 HCPCS Quarterly Update: Policy Updates

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

HCPCS Code Description
C9462 Injection, delafloxacin, 1 mg
C9463 Injection, aprepitant, 1 mg
C9464 Injection, rolapitant, 0.5 mg
C9466 Injection, benralizumab, 1 mg
C9749 Repair of nasal vestibular lateral wall stenosis with implant(s)
Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T Cells, including leukapheresis and dose preparation procedures, per infusion
Q5103 Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg
Q5104 Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg

In addition, codes Q5103 and Q5104 replace terminated code Q5102 (injection, infliximab, biosimilar, 10 mg).

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (21)
Chronic Dialysis Clinics inject cd list (2, 3, 5, 9, 14); inject drug a-d (13–15, 48, 49); inject drug e-h (22); inject drug i-m (8–12); modif app (21)
Clinics and Hospitals
General Medicine
chemo drug a-d (2, 3, 7, 8); chemo drug p-z (10); inject cd list (2, 3, 5, 9, 14); inject drug a-d (13–15, 48, 49); inject drug e-h (22); inject drug i-m (8–12); modif app (21); non ph (11, 13, 24, 26)
Obstetrics
Rehabilitation Clinics
inject cd list (2, 3, 5, 9, 14); inject drug a-d (13–15, 48, 49); inject drug e-h (22); inject drug i-m (8–12); modif app (21); non ph (11, 13, 24, 26)
Pharmacy inject cd list (2, 3, 5, 9, 14); inject drug a-d (13–15, 48, 49); inject drug e-h (22); inject drug i-m (8–12)
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2. 2019 ICD-10-CM/PCS Diagnosis Code Annual Update

Effective for dates of service on or after October 1, 2018, the Centers for Medicare & Medicaid Services (CMS) has added ICD-10-CM and ICD-10-PCS diagnosis codes for the 2019 ICD-10-CM/PCS annual update.

Information and downloads for these codes can be found at the ICD-10 page of the CMS website. Specific billing policy related to this update will be published in a future Medi-Cal Update.

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3. Whole-Child Model Program Implementing in Select Counties

Senate Bill 586 authorizes the Department of Health Care Services (DHCS) to establish the Whole-Child Model (WCM) program in designated County Organized Health Systems (COHS) or Regional Health Authority counties to incorporate California Children’s Services (CCS) program covered services for Medi-Cal eligible CCS children and youth into a Medi-Cal Managed Care Plan (MCP) contract. Under WCM, MCPs assume full financial responsibility for authorization and payment of CCS program-eligible medical services, including authorization activities, claims payments and processing, case management and quality oversight.

Effective July 1, 2018, Phase 1 of the WCM program is implemented in the following counties:

As of the transition date, the CCS program-eligible medical services in WCM counties are carved into MCPs’ capitated rate for those counties. In addition, MCPs are required to cover and ensure the provision of screening, preventive and medically necessary diagnostic and treatment services for clients under the age of 21, including Early and Periodic Screening, Diagnosis and Treatment. CCS program State-Only children with other health coverage will continue to receive services the way they do today and remain the responsibility of the counties.

Service Authorization Requests (SARs) received by WCM CCS programs before June 30, 2018, for Phase 1 are the responsibility of the county to complete. All SARs for services after the Phase 1 WCM start date of July 1, 2018, are to be sent to the MCPs. For the purpose of continuity of care, SARs approved before the transition to MCPs shall remain valid until the end date of the authorization or until the MCPs complete an assessment of the client’s needs. Services carved-out of the MCPs contract are the responsibility of DHCS and will be authorized by DHCS. SARs for carve-out services received by CCS programs or MCPs should be routed to DHCS for authorization.

Providers rendering services for WCM clients should submit their claims directly to the MCP for services rendered on or after July 1, 2018, for Phase 1. Carve-out services authorized by DHCS should be billed to DHCS accordingly. Providers not part of the MCP network are encouraged to become part of the MCP’s provider network. MCPs are required to pay physician and surgeon provider services at rates that are at least equal to the applicable CCS fee-for-service rates unless the physician and surgeon enter into an agreement on an alternative payment methodology mutually agreed upon by the physician, surgeon and the MCP.

DHCS issued additional guidance on California Children’s Services Program Whole Child Model Numbered Letter 04-0618 and the Whole Child Model Provider Notice. Both documents are posted on the California Children’s Services (CCS) Whole-Child Model (WCM) page of the DHCS website. Providers can contact their respective COHS plan provider services should they have any claims or billing inquires.

County COHS Phone Number
Merced, Monterey,
Santa Cruz
Central California Alliance for Health 1-800-700-3874 TTY/TDD
1-877-548-0857
San Luis Obispo,
Santa Barbara
CenCal Health 1-877-814-1861 TTY
1-833-556-2560
San Mateo Health Plan of San Mateo (650) 616-2500 TTY
(650) 616-8037
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4. CCS Service Code Groupings Update

The following code has been end-dated from the California Children’s Services (CCS) Service Code Groupings (SCGs).

Added Codes:
Effective Date Code
June 1, 2018 HCPCS code J3590

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

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 ser (1, 2)
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5. October 2018 Medi-Cal Provider Seminar

The October Medi-Cal provider seminar is scheduled for October 16 – 17, 2018, at the Crown Plaza in Concord, 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 October 2, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After October 2, 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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6. Valid Revenue Codes for Outpatient Services

For dates of service on or after January 1, 2019, a four-digit revenue code must be included on outpatient claims billed on paper UB-04 claim forms (Box 42) or ANSI 837I transactions for electronic billing (FL42; reference ASC X12N 837 v.5010 Loop 2400 Segment SV201).

A revenue code identifies specific accommodations, ancillary services, or unique billing calculations or arrangements. As defined by the National Uniform Billing Committee (NUBC) and required by the HIPAA, services covered in an outpatient setting require a valid four-digit revenue code to accompany the CPT and HCPCS national procedure code(s).

Outpatient claims with dates of service on or after January 1, 2019, that are submitted on paper UB-04 claim forms or ANSI 837I transactions with missing, incomplete, or invalid revenue codes will be denied.

Providers may contact the Telephone Service Center TSC) at 1-800-541-5555 for claims assistance.

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7. 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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8. 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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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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