Medi-Cal Update

Part 1 - Program and Eligibility | January 2019

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1. Remittance Advice Detail Code 010: Denials for Duplicate Claims

A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi-Cal can result in the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.

Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a correction request from that provider.

Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records that may impact beneficiary share of cost, access to services and estate recovery.

For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:

Correspondence Specialist Unit
P.O. Box 13029
Sacramento, CA 95813-4029

For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.

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2. Pediatric Palliative Care Waiver End Date and Transition Plan

The Pediatric Palliative Care (PPC) Waiver that was originally approved by the Centers for Medicare & Medicaid Services (CMS) in 2008 ended on December 31, 2018.

For services provided on or after January 1, 2019, the Department of Health Care Services (DHCS) is educating parents, providers and MCPs about the expansion of pediatric palliative care services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medi-Cal benefit to ensure the continuity of care for children transitioning from the PPC Waiver to receiving palliative care through Medi-Cal's fee-for-service system or a Medi-Cal Managed Care Plan (MCP). EPSDT services are existing Medi-Cal benefits that provide comprehensive, preventive, diagnostic and treatment services to eligible participants under the age of 21, as specified in Section 1905(r) of the Social Security Act. The goal of EPSDT services is to ensure that eligible participants under the age of 21 receive age-appropriate screening, preventive services and treatment services that are medically necessary to correct or improve any identified conditions. The following basic services originally covered under the PPC Waiver will not change under EPSDT services:

Expressive therapies and in-home respite will not be included benefits post-transition.

For additional information on EPSDT services, providers should visit the EPSDT Services page on the DHCS website.

For additional information on the PPC Waiver transition, providers should visit the Partners for Children page on the DHCS website.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (2); mcp spec (12)
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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 will 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 January 1, 2019, Phase 2 of the WCM implemented in the following counties:

As of the transition date, the CCS program-eligible medical services in WCM counties will be 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 beneficiaries under the age of 21, including Early and Periodic Screening, Diagnostic 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 received by WCM CCS programs on or before December 31, 2018, for Phase 2 are the responsibility of the county to complete. All authorization requests for services after the Phase 2 WCM start date of January 1, 2019, must be sent to the MCPs. For the purpose of continuity of care, service authorization requests 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 beneficiary’s needs. Services carved out of the MCPs contract are the responsibility of DHCS and will be authorized by DHCS. Authorization requests for carve-out services received by CCS programs or MCPs should be routed to DHCS for authorization.

Providers rendering services for WCM beneficiaries shall submit their claims directly to the MCP for services rendered on or after January 1, 2019, for Phase 2. 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 through the WCM CCS Numbered Letter 04-0618 and the WCM 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 Provider Services should they have any claims or billing inquiries.

County COHS Phone Number
Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Trinity, Yolo Partnership HealthPlan 1-800-863-4155
1-800-226-2140 TTY/TDD
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4. New Antiviral Drug Doravirine Available for Managed Care Plans

Effective for dates of service on or after August 30, 2018, new antiviral drugs doravirine and doravirine/lamivudine/tenofovir disoproxil fumarate (Delstrigo) are noncapitated services for Managed Care Plans (MCPs), except for the following Health Care Plans (HCPs):

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

Provider Manual(s) Page(s) Updated
Part 1 mcp cohs (6); mcp gmc (8); mcp imperial (6); mcp prim (5); mcp two plan (7)
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5. Risperidone Extended-Release Injection Suspension Capitation Policy

Effective for dates of service on or after July 27, 2018, a long-acting form of risperidone (Perseris), used for the treatment of schizophrenia in adults, is available as a noncapitated benefit in all Managed Care Plans (MCPs) except for the following Health Care Plans (HCPs):

Providers are encouraged to check the Medi-Cal website regularly for updates to the current list of contract drugs and MCP policy.

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6. New PACE Managed Care Plan in Los Angeles County

Effective for dates of service on or after January 1, 2019, Pacific Program of All-Inclusive Care for the Elderly (PACE) opened a new Managed Care Plan (MCP) in Los Angeles County.

PACE is an all-inclusive capitated program designed to coordinate and provide comprehensive medical, social and rehabilitative services needed to restore or preserve the independence of elderly individuals. PACE aims to help recipients live in their communities for as long as medically possible.

Enrollment is voluntary and recipients qualify for plan services if they meet the following criteria:

For more information regarding eligibility, requirements, PACE services or contracting with Pacific PACE, call (650) 242-5908.

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

Provider Manual(s) Page(s) Updated
Part 1 mcp code dir (6); mcp spec (1)
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7. AEVS: Carrier Codes for Other Health Coverage: January 2019 Update

The AEVS: Carrier Codes for Other Health Coverage list has been updated. These codes are updated monthly. Additions and changes are shown in bold and underlined type on the updated provider manual pages. Updates are listed below.

Addition(s)
Code Carrier    
D706 VIBRANTRX ATTN: MEDIMPACT    
H313 HEALTH NET SENIORITY PLUS    
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8. Medi-Cal Suspended and Ineligible Provider List is Updated

The monthly-updated Medi-Cal Suspended and Ineligible Provider List (S&I List) is available on the Suspended and Ineligible Provider List page of the Medi-Cal website.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities.

Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the OIG are subject to Medi-Cal suspension.

Welfare and Institutions Code (W&I Code), section 14043.61, subdivision (a), states, in relevant part, that “a provider shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs, to identify suspended, excluded, or otherwise ineligible providers.”

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9. Medi-Cal Hotlines


Medi-Cal Hotlines  
Border Providers (916) 636-1200
DHCS Medi-Cal Fraud Hotline 1-800-822-6222
Telephone Service Center (TSC) 1-800-541-5555
Provider Telecommunications Network (PTN) 1-800-786-4346

For a complete listing of specialty programs and hours of operation, refer to the Medi-Cal Directory in the provider manual.

Mailing Address:
California MMIS Fiscal Intermediary
PO Box 13029
Sacramento, CA 95813-4029

Medi-Cal Fraud is Against the Law
Medi-Cal fraud costs taxpayers millions each year and can endanger the health of Californians. Help protect Medi-Cal and yourself by reporting violations today.

DHCS Medi-Cal Fraud Hotline: 1-800-822-6222

The call is free and you can remain anonymous. Knowingly participating in fraudulent activities can result in prosecution and jail time. Help prevent Medi-Cal fraud.

Stop Illegal Tobacco Sales
The simplest way to stop illegal tobacco sales to persons under the age of 21 is for merchants to check ID and verify the age of the tobacco purchasers. Report illegal tobacco sales to 1-800-5-ASK-4-ID. For more information, see the California Department of Public Health – California Tobacco Control Program website.

Free Smoking Cessation Resources
The California Smokers’ Helpline provides free help for quitting smoking in multiple languages. Services can be accessed via toll-free hotline 1-800-NO-BUTTS, text, online chat or mobile app. For more information, see the California Smokers’ Helpline website.

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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