Medi-Cal Update

Obstetrics | July 2019 | Bulletin 541

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1. Update: Fiscal Intermediary Transition Frequently Asked Questions

The Department of Health Care Services (DHCS) California Medicaid Management Information System (MMIS) Division is engaged in a multi-year initiative to transition contracts for the Fiscal Intermediary (FI) responsible for the business operations of fee-for-service Medi-Cal.

The transition from the current vendor to the incoming FI, DXC Technology Services, LLC, shall occur on October 1, 2019, with a primary objective being a successful transition without disruptions to state programs, providers or beneficiaries.

As part of our commitment to keeping the provider community informed throughout this process, DHCS began releasing Frequently Asked Questions on the Medi-Cal website. The first round of FAQs was released in a previously published NewsFlash article titled “Fiscal Intermediary Frequently Asked Questions” The following questions and answers are a continuation of this effort.

FI Transition FAQs:

  1. Is Medi-Cal making any changes to Computer Media Claims (CMC)/electronic claim submissions or electronic attachments with the transition to the new FI on October 1, 2019?

    No. Medi-Cal is not making any changes to electronic claims or attachment submission requirements prior to October 1, 2019. Providers and/or submitters are not expected to reapply or retest as part of the vendor transition.

  2. Is Medi-Cal making any changes to the hours of operation for any of the provider or member support areas?

    All areas, with one exception, are retaining the same hours of operation for provider and member support. Effective October 1, 2019, the hours of operation for the Point of Service (POS) Helpdesk/ Internet Help Desk is 8 a.m. to 5 p.m., Monday through Friday, except holidays. Providers and submitters may need to update business or operational practices to align with this change.

  3. Will I need to submit my applications via a different portal from the Provider Application and Validation for Enrollment (PAVE)?

    No. If you currently enroll through PAVE, you will continue to enroll through PAVE. The transition to a new vendor does not impact provider enrollment processes or the PAVE provider enrollment portal PAVE.

  4. Will my current provider ID numbers change once the transition occurs?

    No. The transition will have no impact on provider ID numbers; current provider ID numbers will not change once the transition occurs. Additionally, Provider Identification Numbers (PINs) will not change.

  5. Will my application be fully processed if I am already in the enrollment process during the transition?

    The transition will have no impact on the provider enrollment process, or providers who are in the enrollment process during the transition.

  6. How will I be notified of further changes?

    Updates about the transition will be posted on the Medi-Cal website.

    To receive personalized email notifications with links to the most up-to-date information, providers may subscribe to the Medi-Cal Subscription Service (MCSS) MCSS Subscriber Form on the Medi-Cal website.

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2. July 2019 HCPCS Quarterly Update: Policy Updates

Effective for dates of service on or after July 1, 2019, the following HCPCS codes are Medi-Cal benefits:

HCPCS Code Description
C7956 Fluorescence lymph map with indocyanine green (ICG)
J9030 Injection, BCG live intravesical installation, 1 mg
J9036 Injection, bendamustine HCI (Belrapzo), 1 mg
J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk
Q5112 Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10mg
Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg
Q5114 Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mg
Q5115 Injection, rituximab-abbs, biosimilar, 10mg

Additionally, policy for HCPCS code J9355 (injection, trastuzumab, 10 mg) is updated.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug a-d (9); chemo drug p-z (10, 11, 23–25); inject cd list (3, 4, 6, 15)
Chronic Dialysis Clinics
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (3, 6, 14, 15)
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3. EPSDT: Policy Overview and New Provider Manual Section

The new EPSDT provider manual section is available to help providers understand the scope of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

EPSDT
EPSDT services are a benefit of the Medi-Cal program as specified in Title XIX of the Social Security Act (SSA), Section 1905(r)(5) [Title 42 of the United States Code, Section 1396d(r)]. The benefits covered under EPSDT provide comprehensive and preventive health care services for individuals under 21 years of age who are enrolled in Medi-Cal. These services are key to ensuring that children and youth receive appropriate preventive medical, dental, vision, hearing, mental health, substance use disorder, developmental and specialty services, as well as all necessary services to address any defects, illnesses or conditions identified.

Medical Necessity
The standards to meet medical necessity differ between Medi-Cal and EPSDT. The EPSDT standard is as follows:

EPSDT services are medically necessary or a medical necessity if they correct or ameliorate defects and physical and mental illnesses and conditions discovered through screening. This standard is set forth in Title XIX of the Social Security Act, Section 1905(r)(5) and in Welfare and Institutions Code (W&I Code), Section 14059.5(b)(1).

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

Provider Manual(s)

Page(s) Updated

Part 1 cmc enroll (1, 9); mcp cohs (3); mcp gmc (5); mcp imperial (4); mcp spec (2, 4, 11); mcp two plan (4)
Acupuncture hcpcs iii (1)
Adult Day Health Care Centers audio (2); hcpcs iii (1); ind health (2, 4); ind health cd (3); spe dev (7); tar field (1, 2); ub comp op (10)
AIDS Waiver Program hcpcs iii (1); medi non hcp (2); modif app (10); ub comp op (10)
Audiology and Hearing Aids audio (2); cal child (3); epsdt (1–7); hcpcs iii (1); hear aid bill (6); medi cr cms (5); medi non hcp (2); modif app (10); spe dev (7); tar field (1, 2)
Chiropractic hcpcs iii (1); medi cr cms (5)
Chronic Dialysis Clinics cal child (3); hcpcs iii (1); medi non hcp (2); modif app (10); tar field (1, 2); ub comp op (10)
Clinics and Hospitals cal child (3); epsdt (1–7); hcpcs iii (1); incont (1); ind health (2, 4); ind health cd (3); medi non hcp (2); modif app (10); spec (3); spe dev (7); tar field (1, 2); ub comp op (10)
Durable Medical Equipment cal child (3); hcpcs iii (1); incont (1); medi cr cms (5); medi non hcp (2); modif app (10); spe dev (7); tar field (1, 2)
General Medicine cal child (3); epsdt (1–7); hcpcs iii (1); incont (1); medi cr cms (5); medi non hcp (2); modif app (10); spec (3); tar field (1, 2)
Heroin Detoxification hcpcs iii (1); medi non hcp (2); tar field (1, 2); ub comp op (10)
Home Health Agencies/Home and Community-Based Services cal child (3); hcpcs iii (1); home (5); medi non hcp (2); modif app (10); ped (1–6); tar field (1, 2); ub comp op (10)
Hospice Care Program hcpcs iii (1); medi non hcp (2); tar field (1, 2); ub comp op (10)
Inpatient Services cal child (3); hcpcs iii (1); tar field (1, 2); ub comp ip (11)
Local Educational Agency cal child (3); hcpcs iii (1); modif app (10); ub comp op (10)
Long Term Care epsdt (1–7); incont (1); tar field (1, 2)
Medical Transportation cal child (3); hcpcs iii (1); medi cr cms (5); medi non hcp (2); modif app (10); tar field (1, 2)
Multipurpose Senior Services Program hcpcs iii (1); ub comp op (10)
Obstetrics cal child (3); epsdt (1–7); hcpcs iii (1); medi cr cms (5); medi non hcp (2); modif app (10); tar field (1, 2)
Orthotics and Prosthetics cal child (3); epsdt (1–7); hcpcs iii (1); medi cr cms (5); medi non hcp (2); modif app (10); spe dev (7); tar field (1, 2)
Pharmacy cal child (3); epsdt (1–7); incont (1); medi non hcp (2); tar field (1, 2)
Psychological Services cal child (3); epsdt (1–7); hcpcs iii (1); medi cr cms (5); medi non hcp (2); spec (3); tar field (1, 2)
Rehabilitation Clinics audio (2); cal child (3); hcpcs iii (1); medi non hcp (2); modif app (10); spe dev (7); tar field (1, 2); ub comp op (10)
Therapies audio (2); cal child (3); hcpcs iii (1); medi cr cms (5); medi non hcp (2); modif app (10); spe dev (7); tar field (1, 2)
Vision Care cal child (3); epsdt (1–7); medi non hcp (2); modif app (10); modif used vc (2)
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4. Counseling to Prevent Perinatal Depression is Now Reimbursable

Effective for dates of service on or after February 12, 2019, and consistent with the U.S. Preventive Services Task Force recommendation, Medi-Cal will now reimburse individual and/or group counseling sessions for pregnant or postpartum women with certain depressive, socioeconomic and mental health related risk factors. These risk factors include perinatal depression, a history of depression, current depressive symptoms (that do not reach a diagnostic threshold), low income, adolescent or single parenthood, recent intimate partner violence, elevated anxiety symptoms and a history of significant negative life events.

Up to a combined total of 20 individual counseling (CPT codes 90832 and 90837) and/or group counseling (CPT code 90853) sessions are reimbursable when delivered during the prenatal period and/or during the 12 months following childbirth. Modifier 33 must be submitted on claims for counseling given to prevent perinatal depression.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
preg early (2); preg post (4); prev (8)
Home Health Agencies/Home and Community-Based Services
Inpatient Services
preg post (4)
Obstetrics preg early (2); preg post (4)
Psychological Services psychol (1, 3, 4, 9)
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5. Policy Clarification: Criteria for Cost Avoidance of Prenatal Care Services

A previous Medi-Cal Update article titled “Prenatal Care for Medi-Cal Recipients with OHC is Subject to Cost Avoidance” that published on December 14, 2018, stated that prenatal care services claims for Medi-Cal recipients with Other Health Coverage (OHC) are cost avoided. The following expands on existing criteria for cost avoidance of these claims.

Prior to the Bipartisan Budget Act of 2018, prenatal care services were subject to the optional “pay and chase” method for claim reimbursement. Under the “pay and chase” method, if Medi-Cal reimbursed a service provided to a recipient who also had OHC, Medi-Cal may have attempted to bill the OHC to cover part or all of what Medi-Cal has paid on the claim. This method included claims reimbursed under the global maternity services billing option when prenatal care services could not be differentiated from labor, delivery and postpartum care.

In accordance with the Bipartisan Budget Act of 2018, Section 53102, all prenatal care services are subject to cost avoidance. In addition, any “pay and chase” claim that is bundled with prenatal care services will result in the entire claim being cost avoided.

Standard coordination of benefits will continue to occur for all claims submitted.

A recipient is required to use their OHC prior to their Medi-Cal coverage when the same service is available under the recipient’s OHC. When a service or procedure is not a covered benefit of the recipient’s OHC, a copy of the original denial letter or Explanation of Benefits (EOB) is acceptable for the same recipient and service for a period of one year from the date of the original denial letter or EOB.

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6. Correction to Descriptions for Two DPP Core Maintenance Session Codes

In June 2019, the new Diabetes Prevention Program (DPP) Part 2 provider manual section was released, which listed incorrect month numbers in the descriptions for HCPCS codes G9877 and G9883. The corrected descriptions are as follows:

HCPCS
Code Description
G9877 Two DPP core maintenance sessions were attended by a DPP recipient in months 10-12, and the recipient did not achieve the minimum 5 percent weight loss
G9883 Two DPP core maintenance sessions were attended by a DPP recipient in months 16-18, and the recipient did not achieve the minimum 5 percent weight loss

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Home Health Agencies/Home and Community-Based Programs
Obstetrics
diabetes (6, 7)
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7. Radiology Reimbursement Rate Adjustment

Effective retroactively for dates of service on or after April 1, 2017, the reimbursement rates for radiology services are adjusted.

The rates adjustment will be implemented on July 22, 2019, but will not appear on the Med-Cal rates website until August 15, 2019.

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

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8. Omalizumab Injection Policy Update

Effective for dates of service on or after August 1, 2019, one of the following ICD-10-CM diagnosis codes is required for reimbursement of HCPCS code J2357 (omalizumab, injection, 5 mg):

In addition, the age requirement is updated to 6 years and older.

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
Pharmacy
Rehabilitation Clinics
inject drug n-r (4–6)
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9. Update ICD-10-CM Diagnosis Code Requirement for Nusinersen Injection

Effective for dates of service on or after August 1, 2019, the ICD-10-CM diagnosis code requirement is updated for HCPCS code J2326 (injection, nusinersen, 0.1 mg). The required codes are now only ICD-10-CM diagnosis code G12.0 (infantile spinal muscular atrophy, type I [Werdnig-Hoffman]) or G12.1 (other inherited spinal muscular atrophy). Indications, dosage and authorization requirements for nusinersen are also updated.

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
Rehabilitation Clinics
Pharmacy
inject drug n-r (2, 3)
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10. Drug Safety Communication: Sleep Behavior Risks with Select Sleep Aids

A new DUR Educational Article titled “Drug Safety Communication: Sleep Behavior Risks with Select Sleep Aids” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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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, 2019
NDC Labeler Code Contracting Company’s Name
68418 BIOCODEX, INC.
69853 PORTOLA PHARMACEUTICALS, INC.
71403 EPI HEALTH, LLC
72508 NEOPHARMA INC.
72512 AVERITAS PHARMA, INC.
72721 HEARTWOOD PHARMA
72733 SANOFI US CORPORATION
 
Terminations, effective July 1, 2019
NDC Labeler Code Contracting Company’s Name
16477 LASER PHARMACEUTICALS, 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 (7, 17, 18, 20, 21)
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12. Medi-Cal List of Contract Drugs

The following provider manual section has 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 Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
June 1, 2019 NALTREXONE HCL Restrictions removed drugs cdl p1c (2)
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13. 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 in good standing and 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, certified 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 are posted on the Family PACT website at www.familypact.org and registration information can be found on the Family PACT Learning Management System (LMS) website at www.ofpregistration.org.

Upcoming In-Person Orientations

Sacramento
August 7, 2019
9:00 a.m. – 1:00 p.m.
Sierra Health Foundation
1321 Garden Highway
Sacramento, CA  95833
Oakland
September 17, 2019
10:00 a.m. – 2:00 p.m.
Oakland Endowment
2000 Franklin Street
Oakland, CA  94612

If there are any questions regarding the orientation process, providers may contact the Office of Family Planning at (916) 650-0414 or send an email to ProviderServices@dhcs.ca.gov.

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14. August 2019 Medi-Cal Provider Seminar

The August Medi-Cal provider seminar is scheduled for August 14 - 15, 2019, at the Long Beach Marriott in Long Beach, California. Providers can access a class schedule for the seminar by visiting the Provider Training 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 California Medicaid Management Information System (CA-MMIS) 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, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 31, 2019, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web 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 regional representative.

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

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15. 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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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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