Medi-Cal Update

Obstetrics | November 2017 | Bulletin 521

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1. Updated TAR Criteria for Breast Cancer Gene Analysis

Effective for dates of service on or after December 1, 2017, Treatment Authorization Request (TAR) criteria have been updated for CPT-4 codes 81211 (BRCA1, BRCA2 gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1), 81213 (...uncommon duplication/deletion variants) and 81162 (...full sequence analysis and full duplication/deletion analysis). The once-in-a-lifetime frequency limitation can be overridden with a TAR that meets certain requirements.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (3, 4, 7–9)
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2. Hereditary Colon Cancer Disorders TAR Override Update

Effective for dates of service on or after December 1, 2017, an approved Treatment Authorization Request (TAR) will no longer override the once-in-a-lifetime limitations of pathology CPT-4 codes 81435 and 81436:

CPT-4 Code Description
81435 Hereditary colon cancer disorders; genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11
81436 duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
once (6); path molec (39)
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3. Nusinersen, Bezlotoxumab and Ustekinumab are Medi-Cal Benefits

Effective for dates of service on or after July 1, 2017, the following HCPCS codes are Medi-Cal benefits:

HCPCS Code Description
C9489 injection, nusinersen, 0.1 mg
C9490 injection, bezlotoxumab, 10 mg
Q9989 ustekinumab, for intravenous injection, 1 mg

In addition, code Q9989 replaces terminated code C9487 (ustekinumab, for intravenous injection, 1 mg). Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). No action is required of providers.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
inject cd list (3, 12, 16); inject drug a-d (14); inject drug n-r (2, 9); inject drug s-z (15–17, 19)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (3, 12, 16); inject drug a-d (14); inject drug n-r (2, 9); inject drug s-z (15–17, 19); non ph (10, 11, 22, 24)
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4. New Modifier ZB Required for HCPCS Code Q5102

Effective retroactively for dates of service on or after July 1, 2016, modifier ZB (Pfizer/Hospira) is required when billing for Inflectra with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZB was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZB (anesthesia [emergency services, healthy patient]) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

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
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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5. New Modifier ZC Required for Billing HCPCS Code Q5102

Effective retroactively for dates of service on or after July 24, 2017, modifier ZC (Merck/Samsung Bioepis) is required when billing for Renflexis with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZC was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZC (anesthesia complicated by extracorporeal circulation) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

The new modifier ZC will be available for use January 1, 2018. To avoid claim denials, providers should submit claims for Q5102 with modifier ZC on or after January 1, 2018. Claims submitted for Q5102 without modifier ZC will continue to be accepted.

An Erroneous Payment Correction (EPC) will be generated to accurately adjudicate claims submitted with the CMS modifier ZC with dates of service on or after July 24, 2017. No action is required of providers.

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
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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6. Coming Soon: Online PDF RAD and Medi-Cal Financial Summary

Providers will soon be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions Services 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.

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

No provider payments will be made via PDF RADs. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for additional information.

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 form). The form, which is expected to be modified in December, is located on the Forms page of the Medi-Cal website (www.medi-cal.ca.gov). 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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7. 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 October 1, 2017
NDC Labeler Code Contracting Company's Name
69809 HLS THERAPEUTICS (USA), INC.
69865 DEPO NF SUB, LLC
70437 PUMA BIOTECHNOLOGY, INC.
70510 MITSUBISHI TANABE PHARMA AMERICA, INC.
70655 RENAISSANCE LAKEWOOD, LLC.
71090 STRONGBRIDGE U.S. INC.
   
Terminations, effective October 1, 2017
NDC Labeler Code Contracting Company's Name
11528 CENTRIX PHARMACEUTICAL, INC.
42546 PRUGEN, INC.
69437 CANTON LABORATORIES, LLC.

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 (6, 8, 18, 19)
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8. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs.

A summary of drugs that have been 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.

Changed Drugs

Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2017 INFLUENZA VIRUS VACCINE Strength removed drugs cdl p1b (40)
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9. RTD Generation to be Discontinued in Multiple Phases

The Department of Health Care Services (DHCS) will be phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1) over the next 12 months. The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. 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.

The implementation of each RTD phase-out period will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

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10. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically

  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 278 transactions
    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 278 transactions

Registered providers, clearinghouses or Managed Care Plans 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 other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission 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 (1, 12); genetic (4, 5)
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11. 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 Family PACT Provider Orientation provides an overview of the Family PACT Program, provider enrollment process, program standards and benefits and client eligibility and enrollment.

Solo or group providers or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility.

The Family PACT Provider Orientation is delivered in two parts. Part one consists of an online orientation that must be completed prior to attending a part two in-person orientation. Medi-Cal providers who wish to enroll in the Family PACT Program will be required to complete both the online orientation and attend the in-person orientation. The Family PACT Provider Orientation is open to all site staff.

Complete the orientation process by following three simple steps:

  1. Visit: http://www.ofpregistration.org/ to register and create a profile in the Office of Family Planning Learning Management System (LMS). Once your profile has been set up, you are ready to proceed with the orientation.

  2. Complete part one of the orientation. Part one must be completed in order to register for the (part two) in-person orientation. Print the Certification of Completion when you have completed the online orientation.

  3. Complete part two by attending the in-person orientation. Register through the LMS and select an in-person orientation session. Site certifiers must attend the in-person orientation and are required to present photo identification during registration.
Upcoming In-Person Orientation
Los Angeles
December 5, 2017
1:00 p.m. – 5:00 p.m.
California Endowment
1000 North Alameda Street
Los Angeles, CA  90012

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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12. 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 for urgent announcements and other updates shortly, after posting 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
  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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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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