Medi-Cal Update

Pharmacy | December 2018 | Bulletin 933

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1. Next Pharmacy Provider Self-Attestation Starts January 2019

This article provides information regarding the 2018 calendar year claim volume attestation to fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees for fiscal year 2019 – 2020. These additional details include:

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) is implementing a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this new methodology is a two-tiered, professional dispensing fee based on a pharmacy provider's total (Medicaid and non-Medicaid) annual pharmacy claim volume ($13.20 if less than 90,000 claims per year; $10.05 if 90,000 claims or more). Reporting claim volume is a self-attestation process, submitted electronically.

Note:

DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing less than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete an attestation in order to receive it. Attestations must be resubmitted each calendar year.

The attestation period for calendar year 2018 will be open from January 15, 2019, through February 28, 2019, and will determine the professional dispensing fee component of pharmacy claim reimbursement for claims with dates of service from July 1, 2019, through June 30, 2020 (the state's following fiscal year). The web portal closes at 11:59 p.m. on February 28, 2019, and attestations will not be accepted after that time.

In early January 2019, enrolled fee-for-service Medi-Cal pharmacy providers will receive a mailer that contains the URL for the online attestation portal, as well as a unique login ID and password. Providers should note that most chain pharmacies will not receive the mailer because corporate offices are coordinating attestations for their pharmacies via a home office point of contact.

For additional information regarding the Pharmacy Provider Self Attestation Process, providers should refer to the Pharmacy Provider Self-Attestation FAQs page of the Medi-Cal website.

DHCS received approval in late August 2017 from the Centers for Medicare & Medicaid Services (CMS) for State Plan Amendment 17-002, which modifies Medi-Cal's payment methodology for covered outpatient drugs. Included as part of those changes is the amount of the professional dispensing fee, which will change from its current structure to a two-tiered structure depending upon a pharmacy's total annual claim volume. Providers should refer to the Pharmacy Reimbursement Project page of the DHCS website for additional information on this project.

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2. 2019 CPT Annual Update

The 2019 updates to the Current Procedural Terminology (CPT) codes are available in the 2019 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

For Specialty Programs, current or future benefits for updated CPT codes are reflected in the following PDF documents:

The code additions, changes and deletions are effective for dates of service on or after January 1, 2019. Please refer to the 2019 CPT code book for complete descriptions of these codes.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Long Term Care
Medical Transportation
Therapies
Vision Care
opt ben exc (7)
Chronic Dialysis Clinics inject cd list (9); modif used (4)
Clinics and Hospitals
General Medicine
anest (13); cardio (8–10); eval (16, 22, 28, 29); ev woman (21, 22, 34, 35); inject cd list (9); modif used (4); non ph (9, 10, 23, 24); once (6, 7); opt ben exc (7); path molec (3–15, 19–22, 25–27, 30–36, 39, 40, 46, 60, 61); presum bill (10); radi (3); radi dia (9, 24); radi dia ult (4); rates max (5); spec (2); surg bil mod (7, 8); surg nerv (4, 5); surg urin (3, 6); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Inpatient Services opt ben exc (7); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Local Educational Agency loc ed bil cd (7); loc ed bil ex (12, 14); loc ed serv psych (6)
Obstetrics anest (13); eval (16, 22, 28, 29); ev woman (21, 22, 34, 35); inject cd list (9); modif used (4); non ph (9, 10, 23, 24); once (6, 7); opt ben exc (7); path molec (3–15, 19–22, 25–27, 30–36, 39, 40, 46, 60, 61); presum bill (10); radi (3); radi dia (9, 24); radi dia ult (4); rates max (5); surg bil mod (7, 8); surg urin (3, 6); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Pharmacy inject cd list (9); opt ben exc (7); presum bill (10)
Psychological Services opt ben exc (7); psychol (4–7, 9); psychol cd (2); spec (2)
Rehabilitation Clinics inject cd list (9); modif used (4); non ph (9, 10, 23, 24); opt ben exc (7)
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3. October 2018 HCPCS Quarterly Update: Policy Updates

The October 2018 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the Quarter 4 HCPCS Policy (Medi-Cal) PDF. Only those codes representing Medi-Cal benefits effective October 1, 2018, are included in the list of updates.

Please refer to the 2018 HCPCS Level II code book for complete descriptions of these codes.

Providers should refer to the HCPCS Annual Update page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18)
Clinics and Hospitals
General Medicine
chemo drug e-o (6–8); chemo drug p-z (4); inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13); ophthal (16)
Durable Medical Equipment dura bil wheel (19); dura cd (28)
Orthotics and Prosthetics
Therapies
dura cd (28)
Obstetrics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13)
Pharmacy dura bil wheel (19); dura cd (28); inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18)
Rehabilitation Clinics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13)
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4. Sign Language Interpreter Services Code Conversion Policy Overview

Effective for dates of service on or after January 1, 2019, sign language interpreter services currently billed using HCPCS Level III local codes will be converted to a specified HCPCS Level II national code.

Providers submitting claims with dates of service on or after January 1, 2019, must include the appropriate HIPAA-compliant HCPCS Level II national code described in the Sign Language Interpreter Services Crosswalk published October 2018.

For dates of service on or after January 1, 2019, HCPCS Level III local codes Z0324, Z0326, Z0328 and Z0329 will be discontinued, and any claims submitted with these codes will be denied. HCPCS Level III local codes Z0324 and Z0326 will be replaced by HCPCS Level II national code T1013 (sign language or oral interpretive services, per 15 minutes) and revenue code 0969 (other professional fees) for UB-04 claim forms or ANSI 837I transactions.

Modifier code HM (less than bachelor degree level) will be applicable when billing for sign language interpreter services for dates of service on or after January 1, 2019. Modifier code HM is used to denote that the rendering provider is a certified sign language interpreter.

Provider Resources
Providers should refer to the Miscellaneous Services section of the HIPAA: Code Conversions web page for a complete list of sign language interpreter services code conversion resources.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Adult Day Health Care Centers
Chiropractic
Heroin Detoxification
Hospice Care Program
Inpatient Services
Long Term Care
Multipurpose Senior Services Program
Pharmacy
Psychological Services
sign (3)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
modif app (11); modif used (12); non ph (11, 24); sign (3)
Chronic Dialysis Clinics modif app (11); modif used (12); sign (3)
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 (11); sign (3)
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5. Updates to the List of Contracted Intermittent Urinary Catheters

Effective for dates of service on or after January 1, 2019, products from the manufacturers Bard Medical, Coloplast, Cure Medical, LLC and Hollister Incorporated are added to the List of Contracted Intermittent Urinary Catheters.

Effective for dates of service on or after April 1, 2019, products from the manufacturers Bard Medical/Rochester and ConvaTec Inc. are deleted from the List of Contracted Intermittent Urinary Catheters.

The maximum acquisition cost (MAC) for products deleted from the list is no longer guaranteed by the manufacturer.

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6. Sign Language Interpreter Services Code Conversion Reminder

The sign language interpreter services code conversion will replace HCPCS Level III local codes, commonly referred to as local codes, with HIPAA-compliant HCPCS Level II national codes. This billing requirement for sign language interpreter services is mandated by HIPAA and is effective for claims with dates of service on or after January 1, 2019.

For claims with dates of service on or after January 1, 2019, the sign language interpreter services code conversion will be replacing HCPCS Level III local codes Z0324 and Z0326 with HCPCS Level II national code T1013 (sign language or oral interpretive services, per 15 minutes).

As of January 1, 2019, HCPCS Level III local codes Z0328 and Z0329 used to bill for sign language interpreter services will no longer be reimbursable.

Sign language interpreter services are a benefit to facilitate effective communication with deaf or hearing-impaired Medi-Cal recipients. Recipients are not eligible to receive sign language interpreter services in a health facility that is required by law to provide sign language interpreter services.

Providers are encouraged to watch for sign language interpreter service updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update. Providers may complete the Medi-Cal Subscription Service (MCSS) Form to receive timely notifications related to sign language interpreter services.

For additional information, providers may:

Questions regarding the sign language interpreter services code conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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7. Upcoming Pharmacy Fee-For-Service Changes for Covered Outpatient Drugs

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) is implementing a new fee-for-service reimbursement methodology for covered outpatient drugs. Although the policy effective date mandated by the Centers for Medicare & Medicaid Services (CMS) is April 1, 2017, it will take the state's Fiscal Intermediary additional time to update the claims processing system to reimburse using the new methodology. After system implementation, DHCS intends to make retroactive adjustments for all claims with dates of service between the policy effective date of April 1, 2017, and the date of system implementation. DHCS will provide updates in the upcoming months on how these claim adjustments will roll out.

As outlined in California's State Plan Amendment 17-002 approved by CMS on August 25, 2017, the new reimbursement methodology reflects the following changes:

Pharmacy providers are reminded that until such time that DHCS implements the new fee-for-service reimbursement, the pharmacy dispensing fee shall be reimbursed according to the previous methodology ($7.25 retail or $8 for Long Term Care pharmacies). This includes the dispensing fee submitted for 340B drug claims by covered entities and their contract pharmacies pursuant to Welfare and Institutions Code (W&I Code), Section 14105.46.

Providers should refer to the Pharmacy Reimbursement Project page on the DHCS website for access to additional project resources, including the General Project FAQs. DHCS strongly encourages the Medi-Cal pharmacy fee-for-service provider community to closely monitor upcoming Medi-Cal Update pharmacy bulletins for additional information regarding any future provider events, as well as implementation updates.

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8. 2019 Medi-Cal Provider Training Schedule

The 2019 Medi-Cal provider training schedule is now available. Providers can access Medi-Cal training information and registration details by clicking on the Outreach & Education slideshow area of the Medi-Cal website homepage or by visiting the Training Calendar web page of the Medi-Cal Learning Portal (MLP).

Training Date Webinar or Seminar Location Address
January 2 – 31 Webinar Information posted on the Medi-Cal website
February 13 – 14 Seminar Concord
Crowne Plaza
45 John Glenn Drive
Concord, CA  94520
March 13 – 14 Seminar Ontario
Ontario Airport Hotel & Conference Center
700 North Haven Ave.
Ontario, CA  91764
April 17 Seminar Redding
Red Lion Hotel Redding
1830 Hilltop Drive
Redding, CA  96002
May 15 – 16 Seminar Escondido
California Center For The Arts
340 N. Escondido Blvd.
Escondido, CA  92025
June 4 – 27 Webinar Information to be posted on the Medi-Cal website
July 17 – 18 Seminar Sacramento
Sheraton Grand Sacramento Hotel
1230 J Street
Sacramento, CA  95814
August 14 – 15 Seminar Long Beach
Long Beach Marriott
4700 Airport Plaza Drive
Long Beach, CA  90815
September 17 – 18 Seminar Visalia
Visalia Convention Center
303 E. Acequia Ave.
Visalia, CA  93291
October 29 – 30 Seminar Pasadena
Pasadena Convention Center
300 E. Green Street
Pasadena, CA  91101
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9. January 2019 Medi-Cal Provider Training Webinars

Beginning January 2, 2019, and continuing throughout the month of January, Medi-Cal providers may participate in provider training webinars:

Providers will be able to print class materials and ask questions during the training sessions. Recorded webinars will be archived and available for on-demand viewing from the MLP.

To view the webinars, providers must have Internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal website.

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10. February 2019 Medi-Cal Provider Seminar

The February Medi-Cal provider seminar is scheduled for February 13 – 14, 2019, 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 January 30, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After January 30, 2019, 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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11. PE4PW: Paper Claim Submission Discontinued and Provider Manual Updates

Effective October 31, 2018, the Department of Health Care Services (DHCS) is discontinuing the manual (paper) enrollment process for assisting individuals to apply for the Presumptive Eligibility for Pregnant Women (PE4PW) program.

PE4PW qualified providers (QPs) who assist individuals to apply should discontinue use of the paper MC 263 Application for Presumptive Eligibility for Pregnant Women Program and shred old unused forms. Providers use, instead, a printable version (MC 263-P) available in English and Spanish in the Transactions area of the Medi-Cal website.

The transition period for existing providers and their staff to move from the manual (paper) process to the previously announced Web Portal electronic enrollment process, expires on October 31, 2018.

Claims submitted with paper MC 263 PE Proof of Eligibility identification cards for dates of service on or after January 1, 2019, will not be reimbursable.

QPs who are not using the electronic real-time enrollment process are encouraged to transition, including participating in required PE4PW computer based training (CBT).

PE4PW Provider Manual Sections Revised
Information about the old paper PE4PW enrollment methods has been removed from the Medi-Cal provider manual. PE4PW provider manual sections and checklist will be as follows:

Section Title Update(s)
Presumptive Eligibility for Pregnant Women Paper process information/forms and billing codes removed. Gender references adapted.
Presumptive Eligibility for Pregnant Women: Billing Codes New section
Presumptive Eligibility for Pregnant Women Program Process No updates
Presumptive Eligibility for Pregnant Women Provider Enrollment Instructions No updates
Presumptive Eligibility for Pregnant Women Provider Enrollment Checklist No updates

Computer Based Training Required
The PE4PW CBT available on the Medi-Cal Learning Portal (MLP) helps newly qualified providers use the automated Presumptive Eligibility for Pregnant Women Program Application (MC 263) to grant immediate, temporary Medi-Cal coverage for applicants who think they are pregnant, and who meet PE4PW program qualifications.

PE4PW participating providers must complete this training before access to the MC 263 is granted.

New MLP users must register to obtain a user account. During MLP registration, the user must select “Healthcare Provider” or “Provider Staff” as the type of user, and provide a National Provider Identifier (NPI) before taking the training.

Existing MLP users must verify their user profile upon log in to ensure the type of user is either “Healthcare Provider” or “Provider Staff” and ensure their NPI is associated with the user account. If the user profile has a type of user other than the two mentioned, the user must update the profile before taking the PE4PW training.

Providers who are not registered in MLP, using a valid NPI and under either Healthcare Provider or Provider Staff user types will not be able to see the link to the PE4PW training course in MLP.

Failure to update user profiles to include appropriate user types will delay providers’ access to the provider training, and their ability to help applicants apply for temporary Medi-Cal via the automated PE4PW application.

Accessing the Training
The computer must pass a connectivity test for providers to access the training. Providers should:

Providers who are unsure what user type is associated with their account, or who know their user type needs to be changed, should contact the Telephone Service Center (TSC) at 1-800-541-5555 and select Option 4 and then Option 2. A TSC agent will verify whether information is correct and, if necessary, submit a request to update the user profile. User profiles should be updated within 48 hours. Once a profile is updated, the provider can complete the CBT.

Questions
Questions concerning enrollment, computer based training and other PE4PW issues can be sent to PE@dhcs.ca.gov.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (1–7); presum bill (1–15)
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12. 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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13. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

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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14. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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