Medi-Cal Update

Pharmacy | March 2019 | Bulletin 939

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1. Medi-Cal Website to Get an Updated Look and Feel

This spring, the Medi-Cal website will have an updated look and feel. All of the current content will be migrated to the new website and will be easier to access.

Benefits:

Access to transactions and the Medi-Cal Learning Portal will remain the same.

As the update of the website progresses, the Department of Health Care Services (DHCS) will provide updates on the Medi-Cal website.

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2. Medi-Cal Pharmacy Provider Self-Attestation Portal Now Closed

The online attestation portal for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the reimbursement changes for covered outpatient drugs closed at 11:59 p.m. on February 28, 2019. No additional attestations will be accepted until January 2020, at which time the portal will reopen and pharmacy providers can attest to their 2019 claim volume.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) recently implemented 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 (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process, which must be submitted electronically and must be repeated annually.

Note:

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

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

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

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs on the Medi-Cal website or the Pharmacy Reimbursement Project page on the DHCS website. For inquiries not covered in either, providers may call the Telephone Service Center at 1-800-541-5555 (outside of California, call [916] 636-1980), and select the following options:

  1. Option 1 for English or option 2 for Spanish

  2. Option 1 for Provider

  3. Option 4 for Technical Help Desk

  4. Option 2 for Pharmacy

  5. Option 1 for Provider

  6. Option 1 for NPI – enter NPI followed by the pound key (#)

  7. Option 2 for Pharmacy

After following the steps above, the caller will be directed to an agent.

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3. Claims for Tetanus and Diphtheria Vaccine Erroneously Denied

For dates of service on or after September 1, 2013, claims for CPT code 90714 (tetanus and diphtheria toxoids adsorbed [Td], preservative free, when administered to individuals 7 years or older, for intramuscular use) for recipients 19 years of age and older have erroneously denied.

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

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4. Updates to Policy for Intravitreal Implants

Effective for dates of service on or after October 1, 2016, HCPCS code J7313 (injection, fluocinolone acetonide, intravitreal implant, 0.01 mg), is reimbursable for patients 18 years of age and older. An approved Treatment Authorization Request (TAR) is required for reimbursement. The TAR must include clinical documentation of the following:

Modifier LT or RT is required on the claim.

An Erroneous Payment Correction will be initiated to reprocess affected claims for HCPCS code J7313. No action is required of providers.

Additionally, the TAR criteria for HCPCS code J7311 (fluocinolone acetonide, intravitreal implant) is expanded upon. The TAR must include clinical documentation of the following:

Modifier LT or RT is required on the claim. Patients must be 12 years of age and older for reimbursement.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (6)
Clinics and Hospitals
General Medicine
inject cd list (6); ophthal (15, 16)
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5. Medi-Cal Benefit Rebinyn Billable Under New HCPCS Code

Effective for dates of service on or after April 1, 2019, blood factor Rebinyn is billable under HCPCS code J7203 (Injection Factor IX, [antihemophilic factor, recombinant], glycopegylated, [Rebinyn], 1 IU). A Treatment Authorization Request (TAR) is required when billing code J7203.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
blood (3)
Clinics and Hospitals
General Medicine
blood (3); non ph (13, 26)
Obstetrics
Rehabilitation Clinics
non ph (13, 26)
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6. Epoetin Beta ESRD Therapy a Medi-Cal Benefit

Effective for dates of service on or after April 1, 2019, HCPCS code J0887 (injection, epoetin beta, 1 microgram [for ESRD on dialysis]) is a Medi-Cal benefit for patients 5 years of age and older. An approved Treatment Authorization Request (TAR) is required for reimbursement and must include documentation that demonstrates the following:

ICD-10-CM diagnosis code N18.6 (End stage renal disease) must be included on the claim for reimbursement.

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 cd list (6); inject drug e-h (21–23)
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7. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after December 1, 2018, the Universal Product Number (UPN) 810946020419 for Drylock Technologies, Ltd., 14” Maximum Shaped Pad, item number ILS21400, is added to the List of Contracted Incontinence Absorbent Products.

Effective for dates of service on or after May 1, 2019, the Universal Product Number (UPN) 810946020242 for Drylock Technologies, Ltd., 14” Maximum Shaped Pad, item number ILS21400, is removed from the List of Contracted Incontinence Absorbent Products.

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8. Updated Indication and TAR Criteria for Tumor Treating Field Devices

Effective for dates of service on or after April 1, 2019, reimbursement for HCPCS code E0766 (electrical stimulation device used for cancer treatment, includes all accessories, any type) is specified for the treatment of newly diagnosed glioblastoma in patients 18 years of age and older who meet the following criteria, as described in a Treatment Authorization Request (TAR):

The initial TAR may be authorized for up to three months. Re-authorization may be granted when all of the following criteria are met:

Providers are also reminded that HCPCS code E0766 may only be rented with modifier RR, and may not be purchased as new equipment with modifier NU.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil dme (1, 2, 39); dura cd fre (2)
Orthotics and Prosthetics
Therapies
dura cd fre (2)
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9. Updated Guidance for DRG Reimbursed Claims with More Than 22 Line Items

Effective retroactively for dates of service on or after June 6, 2014, diagnosis-related group (DRG) reimbursed claims that contain more than 22 lines should be divided across multiple pages and assigned a unique Claim Control Number (CCN) for each page. A Claims Inquiry Form (CIF) void must be submitted for all CCNs associated with the stay from admit through discharge to recoup any payments prior to the resubmission of a corrected claim. If all reimbursed CCNs are not voided, including CCNs with zero payment, this can cause the resubmitted claim to deny. A reimbursed claim that is not voided causes the new claim to be a duplicate of the previously reimbursed claim (Remittance Advice Details [RAD] code 010).

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

Provider Manual(s) Page(s) Updated
Part 2 cif co (4, 5)
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10. National Correct Coding Initiative Quarterly Update for April 2019

The Centers for Medicare & Medicaid Services (CMS) are scheduled to routinely release the quarterly National Correct Coding Initiative (NCCI) in Medicaid payment policy updates. These mandatory national edits will be incorporated into the Medi-Cal claims processing system and will be effective for dates of service on or after April 1, 2019.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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11. April 2019 Medi-Cal Provider Seminar

The April Medi-Cal Provider Seminar is scheduled for April 17, 2019, at the Red Lion Hotel Redding in Redding, 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 California Medicaid Management Information System (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 April 3, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 3, 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 representative.

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

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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 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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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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